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Tubercular  meningitis  (p.41(> 


PEDIATRICS 

THE    HYGIENIC   AND   MEDICAL 
TREATMENT 

OF 

CHILDREN 


BY  THOMAS  MORGAN  ROTCH,  M.D. 

PROFESSOR  OF  PEDIATRICS,   HARVARD    UNIVERSITY 


FIFTH  EDITION,  REARRANGED 
AND  REWRITTEN 


ILLUSTRATED      BY      NUMEROUS      ENGRAVINGS      IN      THE 
TEXT    AND    BY    COLORED    PLATES 


PHILADELPHIA     AND      LONDON 
J.      B.       LIPPINCOTT       COMPANY 


5      1940 


Copyright,  1895,  by  J.  B.  Lippincott  Company. 


Copyright,  1901,  by  J.  B.  Lippincott  Company 


Copyright,  1903,  by  J.  B.  Lippincott  Company. 


Copyright,  1906,  by  J.  B.  Lippincott  Company. 


ELECTROTYPED  AND    PRINTED    BY   J.    B.    LIPPI.NCOTT   COMPANY,    PHILADELPHIA,    U.    S.    A. 


M 


TO 


ABRAHAM  JACOBI,  M.D.,  LL.D., 

PROFESSOR  OF  DISEASES  OF  CHILDREN  IN  COLUMBIA  UNIVERSITY,    NEW  YORK, 
FROM  1870  TO   1902, 


THE    MOST    DISTINGUISHED 

STUDENT   AND   TEACHER   OF   PEDIATRICS 

"(N  AMERICA. 


PREFACE  TO  THE  FIFTH  EDITION. 


The  necessity  for  a  new  edition  of  "Pediatrics"  affords  an  opportunity 
to  introduce  many  changes  which  will,  it  is  believed,  bring  the  subject- 
matter  up  to  "the  standard  required  by  the  recent  advances  which  have 
been  made  in  the  investigation  of  disease  and  in  the  modern  methods  of 
treatment.  To  accomplish  this  it  has  been  necessary  to  rewrite  in  large 
part  the  divisions  on  The  Care  of  Premature  Infants,  Feeding,  Diseases  of 
the  Gastro-enteric  Tract,  classified  on  an  etiologic  basis  for  the  first  time 
in  the  history  of  this  important  division  of  medicine,  Diseases  of  the 
Nervous  System,  Rheumatic  Fever,  and  the  Acute  and  Chronic  Affections 
of  the  Joints.  The  remaining  articles  have  been  carefully  reviewed  and 
corrected.  Twenty-eight  new  photographs  and  radiographs  and  one 
colored  plate  have  been  added. 

The  work  of  rewriting  and  revising  this  and  the  previous  two  editions 
has  so  largely  been  shared  with  me  by  Dr.  Maynard  Ladd  that  I  gladly 
acknowledge  my  indebtedness  to  him  for  his  faithful  and  accurate  work, 
especially  in  the  articles  on  Feeding,  on  the  Blood,  and  on  "  Premature 
Infants."  His  work  has  done  much  to  make  this  edition  superior  to  its 
predecessors. 

Sincere  thanks  are  given  to  all  those  Avho  have  aided  in  the  work,  par- 
ticularly to  Dr.  George  A.  Waterman  for  special  information  in  regard  to 
Diseases  of  the  Nervous  System,  to  Dr.  Charles  Hunter  Dunn  for  his 
assistance  in  reconstructing  the  division  on  Diseases  of  the  Gastro-enteric 
Tract  and  the  article  on  Rheumatic  Fever,  to  Dr.  Percy  Brown  and 
Dr.  A.  W.  George  for  aid  in  collecting  the  radiographs  and  photographs, 
to  Mr.  F.  W.  Howe  for  information  in  regard  to  the  elements  of  milk  and 
cereals,  and,  finally,  to  Dr.  John  Lovett  Morse  and  Dr.  John  H.  McCollum 
for  many  valuable  suggestions. 

Thomas  Morgan  Rotch. 

197  Commonwealth  Ave.,   Boston,  Massachusetts, 
December  1,   1906. 


PREFACE  TO  THE  THIRD  EDITION. 


When  another  edition  of  this  work  was  called  for  it  was  found  neces- 
sary^ to  rewrite  it  in  order  to  bring  it  into  accord  with  the  advances  which 
have  been  made  in  the  subject  of  Pediatrics  during  the  past  six  years. 
It  is,  therefore,  offered  to  the  Profession  as  practically  a  new  book.  The 
order  in  which  the  different  subjects  have  been  treated,  and  the  relative 
space  assigned  to  them,  have  m  many  instances  been  radically  changed. 
The  endeavor  has  been  made  to  emphasize  the  practical  character  of  the 
work  by  thoroughly  systematizing  the  etiology,  the  symptomatology,  the 
diagnosis,  and  the  treatment  of  the  various  diseases.  Much  attention  has 
been  devoted  to  the  anatomy  and  physiology  of  early  life  and  to  the  ad- 
vances which  have  been  made  in  the  subjects  of  infant  feeding,  of  bac- 
teriology, and  of  the  blood.  Several  new  colored  plates  and  a  number  of 
radiographs  have  been  added  to  the  illustrations. 

In  acknowledging  the  aid  which  I  have  received  I  owe  special  recogni- 
tion to  my  associate  and  friend.  Dr.  Maynard  Ladd,  for  his  help  in  the 
preparation  of  the  entire  book.  His  interest  and  enthusiasm  have  been 
unflaggmg  and  invaluable.  My  thanks  are  also  offered  to  those  who  have 
by  their  ad'sdce  enabled  me  to  remodel  the  book,  and  I  would  particularly 
acknowledge  the  information  connected  with  the  pathology  which  has 
been  given  so  freely  by  Professor  William  T.  Councilman.  I  am  also 
under  much  obligation  to  Dr.  John  H.  McCollum,  Dr.  Robert  W.  Lovett, 
Dr.  John  L.  Morse,  Dr.  Algernon  Coolidge,  Jr.,  Dr.  John  Dane,  and  Dr.  John 
T.  Bowen.  Dr.  William  P.  Northrup  supplied  for  the  previous  edition 
a  number  of  valuable  plates  illustrating  gastro-enteric  diseases,  and  these 
plates  are  now  retained.  Dr.  Franklin  W.  White  has  been  of  great  ser- 
vice in  the  preparation  of  the  article  on  the  blood.  Dr.  Ernest  A.  Cod- 
man  kindly  furnished  the  plates  of  the  radiographs. 

The  publishers  have  shown  unfailing  courtesy  and  much  liberality. 

Finally,  I  am  greatly  indebted  to  my  medical  associates  throughout  the 
country  for  their  encouragement,  which  has  both  stimulated  me  in  my 
work  and  greatly  aided  me  in  its  completion. 

Thomas  Morgan  Rotch. 
197  Commonwealth  Avenue,   Boston,   Massachusetts. 

vii 


PREFACE  TO  THE  FIRST  EDITION. 


A  few  words  are  perhaps  needed  to  explain  what  I  have  undertaken  to 
do  in  the  following  pages,  and  the  method  of  arrangement  and  classifica- 
tion which  has  been  employed.  There  has  been  no  attempt  to  make  such 
classifications  as  infectious  and  non-infectious  diseases,  because  our 
knowledge  of  the  former  is  increasing  the  number  of  that  class  so  rapidly 
that  for  me  it  no  longer  constitutes  a  practical  division  for  teaching.  The 
book  begins  with  a  consideration  of  the  infant  at  birth,  and  follows  it 
through  its  various  stages  of  development  up  to  puberty.  After  dwelling 
rather  more  at  length  on  normal  development  than  is  usual  in  works  on 
pediatrics,  the  abnormal  conditions  are  discussed.  Beginning  with  the 
diseases  which  would  naturally  be  met  with  in  the  early  periods  of  life, 
and  devoting  considerable  space  to  my  observations  on  the  blood  of  infants 
and  of  young  children,  the  diseases  of  the  different  organs  are  then  con- 
sidered. 

With  the  exception  of  a  few  rare  diseases  of  which  it  was  impossible  to 
get  satisfactory  types,  the  illustrations  represent  actual  cases  of  my  own, 
heretofore  unpublished.  The  colored  illustrations  have  received  my 
closest  attention,  and  the  patients  were  seen  personally  with  the  artist,  so 
as  to  insure  accuracy. 

Tlie  establishment  of  milk-laboratories  during  the  last  three  years  has 
marked  a  new  era  in  preventive  medicine,  and  has  made  possible  the 
scientific  feeding  of  infants.  As  I  believe  that  the  medical  treatment  of  the 
various  abnormal  conditions  arising  in  infants  is  in  the  future  to  be  largely 
dietetic  rather  than  by  means  of  drugs,  I  have  given  unusual  prominence 
to  the  part  of  the  work  which  is  devoted  to  feeding. 

I  have  also  endeavored,  in  conjunction  with  my  colleagues  in  the 
American  Pediatric  Society,  to  simplify  the  nomenclature  of  the  various 
diseases,  in  order  that  physicians  in  different  localities  should  by  using 
identical  names  be  better  able  to  aid  one  another  in  their  investigations. 
A  revision  of  the  nomenclature  of  gastro-enteric  diseases  and  of  those  of 
the  mouth  was  especially  called  for  on  account  of  the  changes  which  have 
followed  our  increasing  knowledge  of  the  etiology  of  these  diseases. 

Thomas  Morgan  Rotch. 
Boston,  Mass.,  October,  1895. 


IX 


CONTENTS. 


DIVISION  I. 


THE  NORMAL  INFANT.  lAGi: 

I. — Introduction 17 

II. — The  Fcetal  Circulation 19 

III. — The  Infant  at  Term 21-39 

Vemix  Caseosa;  Skin;  Cord;  Spine;  Neck;  Head;  Thorax;  Abdo- 
men; Bladder ;  Pelvis ;  Uterus;  Temperature;  Pulse;  Respiration; 
Height;  Weight;  Vitality;  Hands;  Feet;  Bone  Marrow;  Functions; 
Blood;   Lymphatic  System;    Urine;   Intestinal  Discharges. 

IV. — NoRJiAL  Development 39-105 

Cord;  Spine;  Neck;  Head;  Thorax;  Weight;  Abdomen;  Tempera- 
ture; Pulse;  Respiration;  Height;  Feet;  Bone  Marrow;  Skin;  Func- 
tions; Lymphatic  System;  Thyroid  Body;  Urine;  Intestinal  Dis- 
charges; Infantile  Skeletons;  Normal  Infants;  Topographical  Anatomy 
of  Early  Life;  Nursery;  Bathing;  Clothing;  Feet;  Shoes;  Sleep; 
When  to  go  out;  Nursery-Maids;  Mouth;  School;  Defects  of  Posture. 

DIVISION  n. 

FEEDING. 

General  Principles 106 

RL\mil^ry  Gl.\nd 107 

First  Nutritive  Period 109-231 

I. — Maternal  Feeding 110 

II. — Direct  Substitute  Feeding 154 

Wet-Nurses;   Animals. 

III. — Indirect  Substitute  Feeding 158 

Cows;  Chemistrj^  of  Cow's  Milk;  Bacteriology  of  Cow's  Milk; 
Production  of  Sterile  Milk;  Theory  of  Percentage  Modification 
of  Milk;  Rules  for  Feeding;  Milk-Laboratories  and  Percentage 
Feeding;  Illustrative  Cases  of  Percentage  Feeding;  Influence 
of  Fat  on  the  Color  of  Faecal  Discharges;  Artificial  Foods  for 
Infants;  Matzoon,  Kumyss,  Butter-milk. 

Second  Nutritive  Period 232 

Third  Nutritive  Period ; 235 

DIVISION  m. 

general   principles   of   EX.A.MINATION   AND   TREATMENT. 

Method  of  examining  a  Child 236-246 

Lumbar  Puncture;  Rontgen  Light;    Treatment;    Prophylaxis. 

DIVISION  IV. 

PREJL^TURE      INF.iNTS. 

Determination  of  Age 247 

Normal  Development 249 

Appearance  at  Birth 254 

Treatment 254 

xi 


xii  CONTENTS. 

PAGE 

Weight 255 

Incubator  (Brooder) 257 

Feeding 260 

DIVISION  V. 
diseases  of  the  new-born. 

Inheritance.     ]VL\.lformation.     Traumatism 268 

Maternal  Impressions 271 

Diseases  of  the  Head    272-281 

CaputSuccedaneum;  Cephalhsematoma;Meningocele;  Encephalocele;  Anence- 
phalia;  Congenital  Hydrocephalus;  Harelip;  Cleft  Palate;  Tongue-tie;  Ranula; 
Protrusion  of  Ears;    Ophthalmia  Neonatorum. 

Diseases  of  the  Neck 281-282 

Htematoma  of  the  Sterno-cleido-mastoid  Muscle;  Branchial  Fistulse. 

Diseases  of  the  Trunk 282-296 

Mastitis;  Depressed  Sternum;  Prominent  Sternum;  Spina  Bifida;  Rhachis- 
chisis;  Phlebitis  and  Arteritis  Umbilicalis;  Congenital  Umbilical  Hernia  into 
the  Cord;  Fungus  of  the  Umbilicus;  Meckel's  Diverticulum;  Umbilical  Hernia; 
Inguinal  Hernia;  Femoral  Hernia;  Hydrocele;  Undescended  Testicle;  Tumors 
of  the  Testis;  Malformations  about  the  Rectum;  Occlusion  of  the  Vagina; 
Hypospadias;  Epispadias;  Congenital  Obliteration  of  the  Bile-Ducts; 
Congenital  Obliteration  of  the  Intestine;  Congenital  Malformations  of  the 
CEsophagus  and  Stomach. 

Diseases  of  the  Extremities 296-298 

Fingers;  Toes;  Club-Hand  and  Foot;  Congenital  Dislocation  of  the  Hip; 
Congenital  Dislocation  of  the  Knee;  Birth  (Obstetrical)  Paralysis. 

General  Diseases ■  •  ■  298-312 

Asphyxia;  Acute  Fatty  Degeneration  of  the  New-Bo rn  (Buhl's  Disease); 
Infectious  Hsemoglobineemia  of  the  New-Born  (Winckel's  Disease);  Hemor- 
rhage in  Early  Life;  Sclerema  Neonatorum;  Qildema  Neonatorum;  Icterus 
Neonatorum;  Erythema  Neonatorum;  Nsevus. 

DIVISION  VI. 

.  diseases  of  nutrition. 

Rhachitis  (rickets) 313-330 

Chondrodystrophia  FoiTALis  (FcETAL  Rhachitis) 331 

Osteomalacia 334 

Scorbutus  (Scurv^O ' 334 

Infantile  Atrophy 341 

DIVISION  VII. 

diseases  of  the  skin. 

Scabies ^ 349 

Pediculosis 351 

Impetigo  Contagiosa 351 

furunculosis 352 

Molluscum  Contagiosum 352 

Seborrhcea  Capitis  of  Infants 353 

Tinea  Tricophytina 353 

Tinea  Favosa 354 

Tinea  Versicolor 354 

Alopecia  Areata 355 

Pemphigus  Neonatorum 355 

Pemphigus 356 

Epidemic  Pemphigus  Infantilis 356 


CONTENTS.  xiii 

PAGE 

Dermatitis  Exfoliativa  Neonatorum  (Ritter's  Disease) 356 

Dermatitis 358 

sudamina 360 

Erythema 360 

Erythema  Intertrigo 361 

Erythema  Nodosum 362 

Erythema  Urticatum  (Urticaria) 362 

Eczema 363 

Psoriasis 367 

Prurigo 368 

Herpes  Zoster 369 

Pityriasis 371 

Verruca  (Warts) 371 

Lentigo 372 

Melanoderma^  Lenticularis  Progressiva 372 

Lichen .  372 

Ichthyosis 373 

Scleroderma 374 

Acute  Circumscribed  Oedema  (Angio-Neurotic  Qi^dema) 375 

DIVISION  vm. 

specific  infectious  diseases. 

Tuberculosis 376-423 

Acute  Miliary  Tuberculosis;  Chronic  General  Tuberculosis;  Tuberculosis  of 
Lymph-Nodes,  of  Larynx,  of  Trachea,  of  Lungs,  of  Pleura,  of  Gastro-Enteric 
Tract,  of  Peritoneum,  of  Brain;  Tubercular  Meningitis;  Tuberculosis  of  the 
Joints;  Tuberculosis  of  Thyroid  Gland,  of  Thymus  Gland,  of  Pancreas,  of 
Spleen,  of  Liver,  of  Kidney,  of  Bladder,  of  Testicle,  of  Skin. 

Epidemic  Cerebro-Spinal  Meningitis 423 

Typhoid  Fever 439 

Typhus  Fever 451 

Diphtheria 451-469 

Influenza  (la  Grippe) 469 

Malaria 474 

Tetanus  Neonatorum 489 

Erysipelas 480 

Amcebic  Infections 494 

Cholera  Asiatica 495 

Pertussis 496 

Acute  Infectious  Osteomyelitis 502 

Rheumatic  Fever 505 

Syphilis 513 

The  Exanthemata 536-610 

Scarlet  Fever;  Measles;  Rubella;  Variola;  Vaccinia;  Varicella. 

Parotitis  (Mumps) 611 

DIVISION   IX. 

diseases  of  the  mouth,  nose,  ear,  naso-pharynx,  and  pharynx. 

Diseases  of  the  Mouth 613-638 

Nomenclature;  Stomatitis  Catarrhalis;  Stomatitis  Herpetica;  Stomatitis 
Ulcerosa;  Stomatitis  Mycetogenetica;  Stomatitis  Hyphomycetica  (Thrush); 
Stomatitis  Pseudo-Membranosa;  Stomatitis  Gangrsenosa  (Noma;  Cancrum 
Oris)  Glossitis;  Lingua  Geographica;  Microglossia;  Macroglossia ;  Difficult 
Dentition. 


xiv  CONTENTS. 

PAGE 

Diseases  of  the  Nose 638-642 

Rhinitis;  Mucous  Polj-pus;  Epistaxis. 

Diseases  of  the  Ear 642 

Diseases  of  the  Naso-Pharynx 644-648 

Hypertrophy  of  the  PharjTageal  Tonsil  (Adenoid  Growths). 
Diseases  of  the  Pharynx 648-658 

Tonsillitis;     Peritonsillar    Abscess;     Pharyngitis;     Elongation    of     Uvula; 

Retropharj'ngeal  Abscess. 

DIVISION  X. 

diseases  of  the  laryxx,   trachea,  bronchi,  lungs,  and  pleura. 

Diseases  of  the  Larynx 659-664 

Laryngospasmus;   New  Growths;  Foreign  Bodies;  Oedema;  Laryngitis. 

Diseases  of  the  Trachea 664 

Diseases  of  the  Bronchi  .and  Lungs 664-707 

Acute  Bronchitis;  Chronic  Bronchitis;  Fibrinous  Bronchitis;  Bronchial 
Asthma;  Pneumonia;  Pneumococcus  Lobar  Pneumonia;  Lobar  Pneumonia 
due  to  other  Causes;  Acute  Broncho-Pneumonia;  Chronic  Broncho-Pneu- 
monia; Hypostatic  Pneumonia;  Atelectasis;  Emphysema;  Gangrene  and 
Abscess  of  the  Lung. 

Diseases  of  the  Pleura 707-718 

Acute  Pleurisy;  Dry,  Sero-Fibrinous,  Purulent  (Empyema);  Chronic 
Pleurisy;  Hydrothorax;  Pneumothorax. 

DIVISION  XI. 

DISEASES    OF    THE    HEART   AND    PERICARDIUM. 
DiSE.'i.sES  OF  THE  Heart 719-752 

Congenital  Diseases 720-730 

Open  Foramen  Ovale;  Defect  of  the  Ventricular  Septum;  Lesions  of 
the  Pulmonary  Orifice;  Persistence  of  the  Ductus  Arteriosus;  Trans- 
position of  the  Large  Arteries;  Lesions  of  the  Tricuspid  Orifice; 
Lesions  of  the  Mitral  and  Aortic  Orifices. 

Acquired  Diseases 730-748 

Cardiac  Hypertrophy;  Cardiac  Dilatation;  Myocarditis;  Endocarditis, 
Acute,  Chronic;  Mitral  Insufficiency;  Mitral  Stenosis;  Aortic  Insuffi- 
ciency; Aortic  Stenosis;  Tricuspid  Insufficiency;  Tricuspid  Stenosis; 
Pulmonary  Insufficiency  and  Stenosis. 

Functional  Diseases 748 

Diseases  of  the  Pericardium 754 

Acute  Pericarditis;  Chronic  Adhesive  Pericarditis. 

DIVISION  xn. 

diseases  of  the  (ESOPHAGUS,  STOMACH,  AND  INTESTINE. 

The  (Esophagus 767 

The  Stomach 770 

Developmental 770 

Stenosis  of  Pylorus. 
Non-infectious 772 

Mechanical:  Contraction  of  the  Stomach;  Dilatation  of  the  Stomach; 

Ulcers. 

New  Growths 777 

Functional 777 

Nervous  Vomiting;  Recurrent  Vomiting;  Indigestion;  Acute  Gastric 

Indigestion   (Acute  Dyspepsia);  Chronic  Gastric  Indigestion  (Chronic 

Dyspepsia);  Traumatic;  Corrosive  Gastritis. 


CONTENTS.  XV 

PAGE 

Infections 787 

Infectious  Gastritis. 

The  Intestine 790 

Developmental 790 

Non-Infectious 790 

Mechanical:    Dilatation    of    the    Colon;    Volvulus;    Intussusception; 

Hernia;  Fissure:  Prolapse;  Hemorrhoids. 

New  Growths;  Intestinal  Discharges 797 

Functional 797 

Incontinence  of  Fgeces;  Constipation;  Acute  Nervous  Diarrhoea;  Chronic 

Nervous    Diarrhoea;    Tubular;    Indigestion;    Duodenal     Indigestion; 

Intestinal  Indigestion. 
Infections 815 

Dysentery';    Cholera    Infantum;    from    other    Organisms;    Proctitis; 

Appendicitis;   Fistulas. 
Intestinal  Worms 831 

DIVISION  xm. 

dise.4.ses  of  the  liver,  p.vncre-^s,  spleen,  .ajn'd  peritonetlm. 
The  Liver 837 

Icterus;  Acute  Yellow  Atrophy;  Congestion;  Fatty  Infiltration;  Suppurative 

Hepatitis   (Abscess);    Hydatids;   Biliary  Calculi;   New  Growths;   Amyloid; 

Interstitial  Hepatitis  (Cirrhosis). 

The  Pancre^vs 843 

The  Spleen 844 

The  Peritoneum 844 

Acute    Peritonitis;    Peritonitis    of    the    New-Bom;    Acute    Pneumococcus 

Peritonitis;    Chronic  Peritonitis. 

DIVISION  XIV. 

diseases  of  the  kidneys,   BL.\DDER,  .\ND  genital  ORG.INS. 

The  Kidneys 848 

Congenital;  Acquired;  Anuria;  Physiological  Albuminuria;  Albuminuria  of 
Adolescence;  Hsematuria  and  Haemoglobinuria;  Chyluria;  Glycosuria;  Acute 
Degeneration;  Passive  Congestion;  Acute  Glomerular  Nephritis;  Acute 
Interstitial  Nephritis;  Subacute  Glomerular  Nephritis;  Chronic  Glomerular 
Nephritis;  Chronic  Interstitial  Nephritis;  Amyloid  Infiltration;  Acute 
Pyelitis  and  Pyelonephritis;  Clironic  Pyelitis;  Perinephritis;  Hydronephrosis; 
Malignant  Growths  and  Enlargement. 

The  Bladder  and  Genitals 873 

Acute  Cystitis;   Chronic  Cystitis;    Vulvo-Vaginitis 873 

Orchitis 876 

EpididjTnitis 876 

Tumors  of  the  Testicle 876 

Phimosis 876 

Enuresis 877 

Masturbation 879 

DIVISION  XV. 
the  blood,     the  lymph-nodes,     the  ductless  glands. 

The  Blood.  , 880-912 

Normal  Conditions 880 

Abnormal  Conditions 885 

Leukaemia 889 

Pseudo-Leukaemic  An:s.nia  of  Ii   ancv 898 


xvi  CONTENTS. 

PAGE 

Primary  Anaemias 902 

Pernicious  Ansemia 902 

Chlorosis , 907 

Secondary  Anosmias 908 

The  Lymph-Nodes 912-914 

Simple  Acute  Adenitis 912 

Simple  Chronic  Adenitis 913 

The  Ductless  Glands 914 

Diseases  of  the  Thyroid  Gland 914 

Goitre  (Bronchocele) 914 

Hyperaemia  of  the  Thyroid 915 

Myxoedema;  Cretinism 916 

Exophthalmic  Goitre 921 

Acute  Thyroiditis 922 

Tumors  of  the  Thyroid  Gland ' 923 

Diseases  of  the  Thymus  Gland 923 

Diseases  of  the  Adrenal  Glands 924 

Addison's  Disease 924 

DIVISION  XVI. 
diseases  of  the  nervous  system. 

Convulsions 927 

Chorea 932 

Choreiform  Diseases 940 

Myotonia 941 

Epilepsy 942 

Insanity 947 

Idiocy. — Imbecility 947 

Arrested  Psychical  Development 952 

Retarded  Speech 953 

Microcephalus 954 

Mirror  Writing 954 

Hysteria ; 954 

Catalepsy 958 

Simulated  Diseases 958 

Insolation 958 

Concussion 960 

Temporary  Amnesia 960 

Temporary  Aphasia 960 

Headaches 961 

Vertigo 962 

Payor  Nocturnus  (Night-Terrors) 962 

Tremor - 963 

Tetany 964 

Dental  Reflexes 965 

Nystagmus 966 

Gyrospasm  and  Spasmus  Nutans 966 

Reflex  Symptoms  of  the  Ear 966 

Reflex  Symptoms  of  the  Larynx 966 

Paroxysmal  Gasping 968 

Reflex  Symptoms  of  the  Lung 968 

Reflex  Cough 969 

Reflex  Symptoms  of  the  Heart 970 

Reflex  Symptoms^  of  the  STOiLACH.. 970 

Reflex  Symptoms  of  the  Bladder 971 


CONTENTS.  xvii 

PAGE 

Heflex  Symptoms  of  the  Vagina 971 

Heflex  Symptoms  of  the  Rectum 971 

Cerebr.\l  Abscess 972 

Cerebral  Paralysis  (Infantile  Cerebral  Palsies) 972 

Myelitis • 981 

Infantile  Spinal  Paralysis  (Poliomyelitis  Anterior  Acuta) 981 

Paralysis  caused  by  Caries  of  the  Spine 989 

Obstetrical  Paralysis 990 

Neuralgia 993 

Hydrocephalus 993 

Thrombosis  of  the  Cerebral  Sinuses 998 

Athetosis 999 

Intil\-Cr.anial  Tumors 1001 

Cerebr-\l  Syphilis  ...    1004 

Meningitis 1005 

Acute  Encephalitis 1008 

Bulbar  Paralysis 1009 

JHultiple  Neuritis 1009 

Insular  or  Disseminated  Sclerosis 1011 

Hereditary  Ataxia  (Friedreich's  Disease) 1012 

Juvenile  Tabes  (Locomotor  Ataxia) 1012 

Syringomyelia 1013 

Hereditary  Spastic  Paraly'sis 1013 

Family  Periodic  Paralysis 1013 

Progressive  Central  Muscul.\r  Atrophy 1014 

Progressive  Neural  Muscular  Atrophy 1016 

Progressive  Muscular  Dystrophies 1017 

DIVISION  xvn. 

unclassified  diseases  . 

ILemophilia 1021 

Purpura 1022 

Status  Lympil-vticus  (Lymphatism) 1024 

Myalgia 1025 

Atrophic  and  Hypertrophic  Diseases  of  the  Joints 1027 

Infectious  Arthritis 1029 

^Epiphyseal  Hyper.emia  (Growing  Pains) 1031 

Diabetes  Insipidus 1031 

Diabetes  Mellitus 1032 

Hypertrophic  Pulmonary  Osteo-Arthropathy , 1036 


LIST  OF  TABLES. 


TABLE  PAGE 

1.  Relation  of  weight  to  vitality 37 

2.  Length  of  spine  to  sacrum : 40 

3.  Relation  of  cricoid  to  sternum 43 

4.  Circumference  of  head  and  thorax  from  birth  to  thirteen  years 44 

5.  Proportions  of  face  to  cranium 44 

6.  Height  of  posterior  nares 47 

7.  Temporary  teeth.     First  dentition 50 

8.  Permanent  teeth.     Second  dentition 50 

9.  Post-natal  changes  of  fcetal  conditions 54 

10.  Weights  of  the  heart  during  its  development 55 

11.  Three  hundred  and  forty-one  infants  fed  at  the  milk  laboratory 63 

12.  Temperature  of  infant  at  term 65 

13.  Townsend's  temperature  observations 66 

14.  Pulse-rate  for  males 66 

15.  Townsend's  pulse  observations 67 

16.  Respirations  in  infancy  and  childhood 67 

17.  Respirations  in  infants  awake,  asleep,  and  crying 67 

18.  Average  heights  and  weights  from  birth  to  five  years 76 

19.  Average  analysis  of  urine  in  infancy  and  childhood 80 

20.  Temperature  of  the  bath  for  different  ages 94 

24.  General  average  of  twenty-six  analyses  of  human  colostrum  milk 116 

25.  Average  analysis  of  human  milk 120 

26.  Analyses  of  fore-milk,  middle-milk,  and  strippings 125 

27.  Human  breast-milk  analyses 126 

28.  Intervals  and  number  of  day  and  night  feedings 128 

29.  Analyses  of  typical  normal,  poor,  over-rich,  and  bad  milk 134 

30.  Analyses  of  human  milk .■ 137 

31.  Analyses  of  human  milk 138 

32.  Analyses  of  human  milk 138 

33.  Analyses  of  human  milk 138 

34.  Analyses  of  human  milk 139 

35.  Analyses  of  human  milk '. 139 

36.  Analyses  of  human  milk 140 

37.  Analyses  of  human  milk 140 

38.  Analyses  of  human,  cow's,  goat's,  mare's,  and  ass's  milk,  compared 161 

39.  Variation  in  the  composition  of  cow's  milk  according  to  the  breed 163 

40.  Analyses  of  cow's  milk,  fat-free  milk,  whey,  and  creams 168 

41.  Analyses  of  cereal  decoctions 168 

42.  Cow's  milk  as  compared  with  human  milk 178 

43.  Showing  percentages  of  fat  in  different  layers  of  cream 187 

44.  Table  for  the  calculations  of  home  modifications 189 

45.  Proportions  of  whey-proteids  and  caseinogen  in  human  and  cow's  milk 191 

46.  Theoretical  basis  for  feeding  a  healthy  infant  during  the  first  year 196 

xix 


XX  LIST   OF  TABLES. 

TABLE  PAGE 

47.  Practical  limits  of  laboratorj"-  modification,  containing  cereal  decoctions 216- 

48.  Practical  limits  of  laboratory  modification,  plain  cream  mixtures 219 

49.  Practical  limits  of  laboratory  modification,  whey-cream  mixtures 221 

50.  Showing  the  management  of  the  food  and  the  increase  in  weight  of  a  healthy  in- 

fant during  the  first  fifty-two  weeks  of  its  life 222: 

51.  Showing  the  management  of  the  food  and  the  increase  in  weight  of  a  healthy 

infant  during  the  first  fifty-two  weeks  of  its  life 22i 

52.  Showing  death-rate  of  premature  infants  at  the  Debiles  de  la  Matemite,  Paris, 

1895,  '96,  '97 264 

53.  Showing  death-rate  of  premature  infants  at  the  Clinique  Tamier,  Paris  1898 264 

54.  Weight  for  sixty-one  days  of  infant  premature  at  thirty-two  weeks 266- 

55.  Showing  details  of  sixty-four  days  of  life  in  the  incubator  of  an  infant  premature 

at  thirty  weeks 409 

56.  Differential  diagnosis  of  cerebral  meningitis 419 

57.  Statistics  of  tuberculosis  of  the  joints  in  the  Children's  Hospital 427 

58.  The  doses  of  tincture  of  digitalis,  strj'chnine,  nitroglycerin,  and  atropine  at  differ- 

ent ages 464 

59.  The  principal  combinations  of  paroxysms  caused  bj'  the  plasmodium  malariae  ..  .  477 

60.  One  thousand  cases  of  scarlet  fever,  bj'  ages,  with  the  deaths 539 

61.  Percentageof  mortality  of  scarlfct  fever  in  the  Annakinderspital  in  Vienna 558 

62.  Individuals  li-\-ing  in  houses  invaded  by  variola 599 

63.  Differential  diagnosis  between  varicella  and  variola 606 

64.  Differential  diagnosis  of  the  exanthemata 610 

65.  Classification  of  the  diseases  of  the  mouth 614 

66.  Amount  of  chlorate  of  potassium  at  different  ages 622 

67.  Differential  diagnosis  between  a  dilated  heart  and  a  pericardial  exudation 761 

68.  Classification  of  diseases  of  the  gastro-enteric  tract 770 

69.  Pfaundler's  index,  showing  diameter  of  lumen  of  pylorus 771 

70.  Showing  prognosis  in  infectious  and  non-infectious  diarrhoea 821 

71.  Average  percentages  of  the  different  elements  of  the  blood  in  the  splenic  mye- 

logenous and  IjTiiphatic  leukaemias 891 

72.  Showing  blood  changes  in  a  case  of  acute  Ij-mphatic  leukgemia 896 

73.  Differential  diagnosis  between  cerebral  paralysis  and  poliomyelitis  anterior 984 


LIST  OF  ILLUSTRATIONS. 


COLORED  PLATES  AND  RADIOGRAPHS. 

PLATE  PAGE 

I.  a.  Tubercular  meningitis,  convexity  of  brain Frontispiece 

b.  Tubercular    meningitis,    base    of    brain Frontispiece 

II.  Icterus  neonatorum.    Red  bone-marrow.    Yellow  bone-marrow.    Erythema 

neonatorum 75 

III.  Intertrigo.     Seborrlicea  capitis.     Umbilical  cords.     Napkins 77 

IV.  Radiograph  of  the  chest  and  abdomen 244 

V.  Radiograph  in  a  case  of  rhachitis,  showing  marked  deformity  of  the  legs ....  324 

^T.  Radiographs  of  osteomyelitis  of  the  lower  end  of  the  femur,  and  of  tuber- 
culosis of  the  knee-joint 504 

YLI.  Radiograph  of  the  tibise  and  j&bulEe  in  syphilis 528 

VIII.   Scarlet  fever.     Measles 560 

IX.  Koplik  spots 580 

X.  Vaccination 600 

XI.  Erysipelas.     Varicella.     Syphilis 606 

XII.  Mouth   and   throat    in   thrush,    varicella,    stomatitis   herpetica,    stomatitis 

ulcerosa,  follicular  tonsillitis,  diphtheria 618 

XIII.  Hydropneumothorax,   upright   position 716 

XIV.  Hydropneumothorax,    dorsal   position 718 

XV.  Blood-corpuscles.     Mosquitoes,  genus  Anopheles,  genus  Cxilex 884 

FIGURES. 

FIG.  PAGE 

1.  Fcetal  circulation 19 

2.  Heart,  natural  size,  at  two  days 20 

3.  Spinal  curves 23 

4.  Skull  of  infant  at  term,  natural  size 25 

5.  Section  of  fcetal  lung  at  five  months 32 

6.  Section  of  infant's  lung  at  ten  months 32 

7.  Lobulated  kidney,  natural  size 34 

8.  Stomach,  natural  size.     Infant,  three  hours  old 34 

9.  Respiration  at  birth,  illustrative  diagram 36 

10.  Infant  skull,  natural  size 45 

11.  Skulls  showing  development  of  ramus  at  birth  and  at  three  years 48 

12.  Five  periods  of  development  in  the  first  dentition 49 

13.  Eight  periods  of  development  in  the  second  dentition 51 

14.  Respirations  for  one-half  minute  in  a  healthy  infant  nine  months  old 52 

15.  Frozen  section,  child  of  three  years 53 

16.  Heart,  showing  Eustachian  Yalve  and  foramen  ovale 55 

17.  Heart,  showing  ductus  arteriosus 55 

18.  Stomach,  spleen,  and  pancreas  at  ten  months 56 

19.  Stomach  of  infant  two  and  one-half  days  old,  natural  size 60 

xxi 


xxii  LIST   OF  ILLUSTRATIONS. 

FIG.  PAGE 

20.  Stomach  of  infant  five  days  old,  natural  size 60 

21.  Stomach  of  infant  seven  daj's  old,  natural  size 61 

22.  Stomach  of  infant  twelve  days  old,  distended  to  hold  eighty, c.c 61 

23.  Stomach  of  infant  five  months  old,  distended  to  hold  two  hundred  and  twenty- 

five  c.c 61 

24.  Stomach  of  infant  seven  months  old,  natural  size 62 

25.  Stomach  of  infant  nineteen  months  old,  natural  size 62 

26.  Skeleton  of  infant  at  term 82 

27.  Skeleton  of  infant  at  nineteen  months 82 

28-29.  Normal  infant  seven  months  old 83 

30-31.  Normal  development  at  six  yeai-s 85 

32-33.  Normal  development  at  twelve  years 86 

34.  Infant's  bed.  Infants'  Hospital 88 

35.  A,  B,  C,  D,  E.     Long  clothes  for  infants 95 

36.  F,  G,  H,  I,  J.     Short  clothes  for  infants  and  children 97 

37.  Shape  of  soles  for  a  child's  shoe 99 

38.  Posterior  spinal  curvature  from  sitting  too  soon 104 

39-40.  Lateral  curvature  of  the  spine.     Child,  four  and  one-half  years  old 105 

41.  Breast-pump 113 

42.  Colostrum  milk  from  cow  (photomicrograph) 116 

43.  Colostrum  milk  from  woman  (photomicrograph) 116 

44.  Apparatus  for  home  modification 185 

45.  Sugar-measure 186 

46.  Jar  containing  milk,  cream,  and  siphon 187 

47.  Unmodified  cow's  milk.    206 

48.  Cow's  milk  separated  and  recomposed 206 

49.  Human  milk 207 

50.  Modified  cow's  milk 207 

51.  Centrifugal  separator 211 

52.  Babcock  fat-tester 212 

53.  Apparatus  for  the  transportation  of  milk 213 

54.  Ice-box  for  the  transportation  of  modified  milk 214 

55.  Phonendoscope 241 

56.  Tongue  depressor 241 

57.  Fcetal  stomach,  natural  size,  four  and  one-half  montlis  old 250 

58.  Foetal  stomach,  natural  size,  seven  and  one-half  months  old 250 

59.  Foetal  stomach,  natural  size,  eight  months  old 250 

60.  Foetal  stomach,  natural  size,  eight  months  old 250 

61.  Infant  premature  at  seventh  month 254 

62.  Incubator  for  premature  infants 257 

63.  Infant  premature  at  the  twenty-eighth  week 258 

64.  Feeder  for  premature  infants. 260 

65.  Infant  premature  at  thirty  weeks.     Age.  nine  months 266 

66.  Caput  succedaneum.     Male,  two  hours  old 272 

67.  Double  cephalhsematoma.     Infant,  four  days  old 273 

68.  Double  external  cephalhsematoma.      Both  parietal  bones 274 

69.  External  cephalhaematoma.     Parietal  bone  dissected 274 

70.  Meningocele.     Female,  three  years  old 275 

71.  Hydro-encephalocele.     Female,  two  months  old 277 

72.  Double  harelip. 278 

73.  Congenital  depression  of  sternum.     Male,  six  years  old 283 

74.  Spina  bifida.     Male,  four  and  one-haU  years  old 285 

75.  Spina  bifida  of  dorsal  lumbar  region 286 

76.  Spina  bifida  of  lumbar  region 287 

77.  Large  umbilical  hernia.     Infant,  five  months  old 289 


LIST   OF   ILLUSTRATIONS.  xxiii 

FIG.  PAGE 

78-  Nsevus  of  face  and  neck  in  an  infant  four  months  old 312 

79-  I.  Normal  bone,     II.  Bone  of  cretin.     III.  Rhachitic  bone  316 

80.  Spindle-shaped  rhachitic  bone 318 

81.  Inner  surface  of  sternum,  showing  rhachitic  rosary 322 

82.  Rhachitic  kyphosis 322 

83.  Showing  deformities  of  the  humeri  in  a  case  of  rhachitis 323 

84.  Rhachitis,  with  enlarged  spleen.     Male,  three  years  old 325 

85.  I.  and  II.  Rhachitis.    Age  six  years 328 

86.  Chondrodystrophy  foetalis 332 

87.  Chondrodystrophy  foetalis 333 

88.  Section  of  scorbutic  bone 336 

89.  Vertical  section  of  a  leg  in  a  case  of  infantile  scorbutus 336 

90.  Infantile  scorbutus.     Female,  ten  months  old 339 

91 .  Infantile  scorbutus  in  an  infant  of  nine  months .  , 340 

91a.  Infantile  atrophy.     Female,  nine  months  old 346 

:  92.  Infantile  atrophy.     Female,  ten  months  old. 346 

93.  Infantile  atrophy.     Female,  one  and  one-half  years  old 347 

94.  Infantile  atrophy,  showing  extreme  emaciation 348 

95.  Tinea  tonsurans,    Male,  eight  years  old 354 

96.  Dermatitis  medicamentosa,  from  bromide  poisoning 359 

97.  Eczema  capitis 365 

98.  Method  of  treating  eczema  capitis 366 

99.  Lesion  of  herpes  zoster  in  a  girl  of  four  years 370 

100.  Chronic  pulmonary  tuberculosis  with  involvement  of  the  cervical  lymph-nodes  386 

101.  Chronic  tuberculosis  of  the  lungs.    Female,  eight  years  old 393 

102.  Tubercular  ulcers  of  the  colon 394 

103.  I.  Tubercular  ulcers  of  the  small  intestine 394 

103.  II.  Large  tubercular  ulcer  of  the  caecum. 395 

104.  Tubercular  meningitis.    Male,  three  years  old 413 

105.  Recurrent  tubercular  meningitis.    Female,  twenty-one  months  old 415 

106.  Extreme  opisthotonos  in  a  case  of  cerebro-spinal  meningitis 425 

107.  Chronic  intermittent  cerebro-spinal  meningitis.    Female,  eight  years  old  ......  435 

108.  Secondary  choroido-iritis,  occurring  in  cerebro-spinal  meningitis 436 

109.  Chronic  cerebro-spinal  meningitis,  with  spastic  condition  of  the  hand 437 

110.  Typhoid  fever.     Male,  five  years  old 449 

111.  Typhoidal  ileo-colitis,  showing  ulcers  of  the  colon.    Female,  two  years  old 450 

112.  Enlarged  Peyer's  patches  closely  simulating  the  lesions  of  ileo-colitis 451 

113.  Malaria.     Enlarged  spleen.     Boy,  nine  years  old 484 

114.  Malaria.     Enlarged  spleen.      Girl,  nine  years  old 486 

115.  Pertussis  during  paroxysm.     Female,  four  years  old 498 

116.  Osteomyelitis  of  the  radius 503 

117.  Rheumatic  fever.     Adult  type  of  the  disease,     Male,  three  and  a  half  years  old  510 

118.  Rheumatic  fever.    Subcutaneous  fibrous  nodules.    Male,  thirteen  years  old  ...  .  512 

119.  Syphilitic  maculae,  ulcers,  and  bullae  on  the  soles  of  the  feet.     Male,  two  and 

one-half  months  old 528 

120.  Congenital  syphilis.    Enlarged  spleen,    Male,  two  and  one-half  months  old  ....  528 

121.  Syphilitic  teeth  of  the  second  dentition 530 

122.  Syphilitic  teeth  of  the  second  dentition 530 

.123.  Periostitis  of  humeri  and  tibiae  in  congenital  syphilis 531 

■124.  Late  manifestations  of  syphilis.    Female,  three  and  one-half  years  old 534 

125.  Interstitial  nephritis.     Sectionof  kidney  from  child  with  scarlet, fever.  .. 546 

126.  Capsular  glomerulo-nephritis.    Section  of  kidney  from  child  with  scarlet  fever  547 
d27.  Typical  condition  of  the  face  in  measles,  fifteen  days  from  infection.    Female, 

six  years  old . .. , 584 

128.  Varicella.     Stage  of  efflorescence,  third  day. .....  .  .  . 608 


xxiv  LIST   OF    ILLUSTRATIONS. 

FIG-  PAGE 

129.  Enlargement  of  submaxillary  glands 612 

130.  Mycelium  of  thrush,  interspersed  with  spores  and  fatty  degenerated  cells 626 

131.  Thrush,  showing  the  formation  of  spores  in  the  mycelium 627 

132.  Stomatitis  gangraenosa,  left  cheek.    Female,  four  years  old 630 

133.  Stomatitis  gangrjenosa  secondary  to  measles  and  pneumonia.      Female,  five 

years  old 630 

134.  Showing  the  connection  between  the  sensori-motor  nerves  and  the  sjnnpathetic  633 

135.  Showing  the  anatomical  nervous  connection  between  the  teeth  and  the  mem- 

brana  tpnpani 63-4 

136-137.  Showing  the  relations  of  the  teeth  to  the  gums  in  difficult  dentition 635 

13S.  Gum-lancet 636 

139.  Hj-pertrophy  of  the  pharjmgeal  tonsil  (adenoid  growths).      Female,  ten  years 

old 646 

140.  Retropharj-ngeal  abscess.    Male,  seven  montlis  old 657 

141.  Retrophan,-ngeal  abscess  secondan,'  to  cervical  spondylitis 658 

142.  Section  of  a  child's  lungs  in  acute  bronchitis 666 

143.  Lobar  pneumonia.     Female,  eight  years  old 688 

144.  Lobar  pneumonia.     Three  invasions.     Male,  six  years  old 688 

145.  Broncho-pneumonia  complicating  measles.     Early  stage 692 

146.  Broncho-pneumonia  secondan,'  to  diphtheria 693 

147.  Chronic  broncho-pneumonia 695 

148.  Acute  broncho-pneumonia.     Female,  four  and  one-half  years  old 702 

149.  Congenital  cardiac  disease.    L'nclosed  ventricular  septum.    Female,  ten  months 

old 727 

1.50.  Congenital  cardiac  disease.     Stenosis  of  pulmonary  orifice.     Incomplete  sep- 
tum ventriculorum.    Male,  four  and  one-half  years  old 728 

151.  Congenital  cardiac  disease.     Transverse  section  of  heart  near  apex,  showing 

thickened  septum  ventriculorum 72& 

152.  Congenital  cardiac  disease.    Open  ductus  arteriosus.    Male,  sixteen  days  old ..  .  729 

153.  Acute  endocarditis.    Mitralinsufficiency.    Lacking  compensation.  Orthopnoea. 

Female,  nine  years  old 750 

154.  Chronic  lecurrent  endocarditis.    Mitral  insufficiency.    Disturbance  of  compen- 

sation.    Dilated  heart.     Enlarged  liver.     CEdema  of  lungs.     Ascites. 

Male,  ten  years  old 752 

155.  Chronic  endocarditis.     Mitral  insufficiency.     General  cedema  and  ascites 752 

156.  Chronic  endocarditis.     Mitral  insufficiency.     Returning  compensation.     En- 

larged liver.    Enlarged  heart 753 

157.  Chronic  endocarditis.     Mitral  insufficiency  with  returned  and  complete  com- 

pensation    753 

158.  Areas  of  absolute  dulness  in  enlarged  heart  and  in  distended  pericardium    760 

159.  Congenital  dilatation  of  the  oesophagus.     Female,  ten  weeks  old 768 

160.  Dilated  stomach.     Rhachitic  infant,  seven  months  old 774 

161.  Dilatation  of  the  stomach.    Age,  six  years 776 

162.  FolHcular  ulceration  of  the  stomach.     Female  one  year  old 788 

163.  Dilatation  of  the  colon.     Male,  twelve  years  old 791 

164.  Colon  showing  presence  of  bismuth  which  liad  been  given  by  the  mouth 811 

165.  Hj-perplasia  of  the  lymph-follicles 816 

166.  Non-ulcerative  follicular  inflammation.    Simple  hyperplasia  of  the  lymph-folli- 

cles.    Female,  three  years  old 816 

167.  Colitis  foUicularis  non-ulcerativa.     Male,  two  years  old following  816 

168.  Colitis  foUicularis  non-ulcerativa "  816 

169.  Microscopic  section  of  hjT^erplasia  of  Ijmiph-follicles  (solitary  glands)  .         "  816 

170.  Microscopic  section  of  follicular  ulceration  of  the  colon "  816 

171.  Ileo-cohtis      Ulcerative  foUicularis.     Infant  sixteen  months  old /'  816 

172.  Acute  ulcerative  catarrhal  cohtis.     Female,  three  months  old "  816 


LIST    OF    ILLUSTRATIO-XS.           "  XXV 

FIG.  PAGE 

173.  Inflammation  of  follicles  and  surrounding  parts  of  the  colon,  with 

necrosis.     Female,  three  months  old following  816 

174.  Pigmented  follicular  ulcers  of  the  colon.    Chronic  catarrhal  ulcerative 

follicular  colitis "  816 

175.  Pseudo-membranous  colitis.     Cliild,  three  and  one-half  years  old "  816 

17o.  Microscopic  section.    Pseudo-membranous  colitis.     Female,  four  years  old 817 

177.  Microscopic  section.     Superficial  necrosis  of  the  mucosa  of  the  colon,  with 

swelling  of  the  lymph-follicles 817 

178.  Oxyuris  vermicularis.     Ascaris  lumbricoides 832 

179.  Taeniae:    I.,  without  head;  II.,  with  head 835 

ISO.  Amyloid  liver.      Pulmonary    tuberculosis.      Male,    seven   and   three-fourths 

years  old 841 

181.  Hypertrophic  cirrhosis.     Female,  eighteen  months  old 843 

182.  Acute  diffuse  nephritis,  following  scarlet  fever 860 

183.  Probable  chronic  parenchjonatous  nephritis  with  an  acute  exacerbation.    Male, 

ele^'en  years  old 866 

184.  Probable  chronic  parenchymatous  nephritis  with  an  acute  exacerbation.     Fe- 

male, nine  years  old 867 

185.  Acute  lymphatic  leukaemia  in  a  girl  of  three  and  one-half  years 895 

186.  Chronic  cervical  adenitis 914 

187.  Hypersemia  of  the  thyroid  gland.    Female,  thirteen  years 915 

188.  Sporadic  cretinism  in  an  infant  ten  months  old 917 

189.  Myxoedema.    Female,  five  and  one-half  years  old 918 

190.  Myxoedema.    Female,  nine  years  old 919 

191.  Rheumatic  arthritis.    Endocarditis.    Cardiac  enlargement.    Chorea.     Female, 

eight  years  old 939 

192.  Microcephalic  idiot,  ten  years  old 948 

193.  Tetany  in  an  infant  of  six  months 964 

194.  Reflex  connection  between  the  ear  and  larynx 968 

195.  Cerebral  paralysis.    Spastic  paraplegia.    Cross-legged  progression.    Male,  five 

and  one-half  years  old 980 

196.  Cerebral  paralysis.    Diplegia.    Female,  five  years  old 980 

197.  Poliomyelitis  anterior.     Left  leg.     Female,  nine  years  old 987 

198.  Poliomyelitis  anterior.    Abdominal  muscles,  left  side.     Female,  two  and  one- 

half  years  old 987 

199.  Poliomyelitis  anterior.    Flail-leg,  left  side.    Male,  six  and  one-half  years  old.  ..  .  988 

200.  Poliomyelitis  anterior.    Talipes  equinus,  right  side.    Male,  eleven  and  one-half 

years  old '  988 

201.  Obstetrical  paralysis  in  a  girl  of  twenty  months 991 

202.  Hydrocephalic  brain 995 

203.  Hydrocephalic  skull,  child  three  years 994 

204.  Normal  skull,  child  three  years 994 

205.  Congenital  internal  hydrocephalus.     Male,  seven  months  old 997 

206.  Congenital  internal  hydrocephalus.     Female,  five  years  old 997 

207.  Congenital  athetosis.     Female,  two  years  old 1000 

208.  A.  and  B.     Sarcoma  of  the  brain  in  a  girl  of  two  and  one-half  years 1001 

209.  Sarcoma  of  the  skull  in  a  boy  of  two  years 1002 

210.  Pseudo-hypertrophic  muscular  paralysis,  showing  enlarged  calves 1020 

211.  Pseudo-hypertrophic  muscular  paralysis,  showing  position  assumed  in  rising 

from  the  floor 1020 

212.  I.  and  II.    Acute  rheumatic  torticollis.     Fifth  day  of  attack 1027 

213.  Chronic  pulmonary  osteo-arthropathy  in  a  boy  three  and  three-fourths  years 

of  age 1036 


PEDIATRICS, 


DIVISION   I. 

THE     NORMAL     INFANT. 


I.    INTRODUCTION. 


Pediatrics  is  a  branch  of  medicine  of  the  greatest  practical  importance. 
Those  who  enter  into  general  practice  will  at  once  be  called  upon  to  treat 
infants  and  children.  The  proper  appreciation  of  the  sensitive  tempera- 
ments and  needs  of  this  class  of  patients  will  be  of  great  aid  in  success- 
fully establishing  a  practice  among  those  whose  favorable  opinion  may 
make  or  mar  professional  success.  The  difficulties  to  be  surmounted  in 
correctly  diagnosticating  and  treating  young  children  are  far  greater  than 
those  which  are  encountered  in  adult  life.  The  reason  for  this  is  that  for 
adult  cases  there  is  some  standard  by  Avhich  we  can  be  guided,  being  our- 
selves adults.  What  standard,  however,  is  there  for  the  feelings  and 
sensitive  organization  of  theV'hild  ?  We  have  none  within  ourselves ;  it 
must  all  come  from  long  and  patient  observation,  with  its  resulting  expe- 
rience. The  mere  knowledge  that  certain  diseases  exist,  and  the  usual 
methods  of  diagnosticating  them,  prove  to  be  very  inadequate  when  we 
are  brought  face  to  face  with  a  sick  and  fretful  child,  or  with  an  infant  who 
is  unable  to  describe  its  symptoms.  Much  additional  knowledge  is  needed 
to  enable  us  to  understand  the  variety  of  symptoms  which  may  arise  in 
the  same  disease  according  to  the  age  and  individuality  of  the  patient.  It 
is  noAV  well  recognized  that  there  is  a  necessity  for  making  a  special  study 
of  children  beyond  Avhat  is  learned  in  the  general  clinical  study  of  adults. 
As  our  kno^vledge  advances,  we  learn  to  appreciate  that  the  various 
methods  of  treatment  must  be  modified  to  correspond  not  so  much  to  the 
special  disease  as  to  the  special  group  of  symptoms  brought  about  by  the 
age  of  the  individual  and  the  phase  of  its  development.  In  studying, 
then,  the  different  stages  of  development  in  children,  Ave  are  in  reality 
acquiring  an  alphabet,  which  when  once  thoroughly  mastered  will  enable 
us  to  read  the  otherwise  obscure  language  presented  to  us  for  translation 
by  the  various  diseases  of  early  life.     The  proper  method  of  learning  to 


18  PEDIATRICS. 

understand  sick  infants  and  children  is  first  to  notice  their  peculiarities  in 
health  and  to  follow  these  peculiarities  through  the  different  stages  of  their 
development  up  to  puberty.  Thus,  a  pulse  which  would  indicate  an 
abnormal  condition  in  the  adult,  or  a  convulsion  which  would  be  of 
serious  import  in  the  older  subject,  may  often  be  but  pliysio logical  or 
of  slight  consequence  in  the  child.  In  fact,  there  are  a  large  number  of 
physiological  and  anatomical  truths  concerning  the  young  the  knowledge 
of  which  will  simplify  to  a  great  degree  otherwise  almost  insurmountable 
difficulties  in  diagnosis.  The  lack  of  this  preliminary  training,  this 
alphabet,  places  the  student  who  is  endeavoring  to  understand  diseases 
in  children  in  the  position  of  attempting  to  read  without  having  first 
learned  his  letters.  It  is  the  province  of  pediatrics  to  begin  with  the 
human  being  at  birth,  to  study  it  as  it  appears  in  the  early  hours  of  life, 
and  to  follow  it  in  its  development  during  the  periods  of  infancy  and 
childhood  up  to  the  age  of  puberty.  For  purposes  of  simplicity,  we 
speak  of  infants  and  children,  the  anatomical  and  physiological  conditions 
being  sufficiently  apparent  to  warrant  this  distinction  between  them.  The 
period  of  infancy  is  usually  spoken  of  as  covering  about  the  first  two 
years  of  life.  Its  most  distinctive  features  are  presented  in  the  first 
twelve  months,  the  second  year,  month  by  month,  rapidly  approaching 
the  conditions  which  exist  in  childhood.  The'  second  year,  however,  is 
influenced  to  such  a  degree  by  the  various  growing  functions  and  tissues 
that  its  picture  both  in  health  and  in  disease  resembles  more  closely  the 
infant  than  the  child.  Childhood  is  empirically  reckoned  from  the  end 
of  infancy  to  puberty,  or  the  beginning  of  adolescence.  A  distinction 
must  be  made  between  the  sexes,  the  girl  becoming  a  fuUy  developed 
woman  some  years  before  the  boy  becomes  a  man.  The  age  of  puberty 
is  usually  reckoned  as  beginning  from  the  twelfth  to  the  fourteenth  year. 
Much  latitude  as  to  age,  however,  must  be  given  for  the  special  idiosyn- 
crasy of  the  individual,  and  also  for  the  climate,  as  it  has  been  found  that 
children  who  live  in  a  warm  cHmate  arrive  at  the  age  of  puberty  much 
earlier  than  those  who  are  exposed  to  the  lower  ranges  of  temperature. 
In  taking  the  period  of  birth  as  a  starting-point  for  our  studies  we  must 
not  overlook  the  fact  that  it  is  simply  a  stage  of  development  with  which 
we  are  dealing,  and  not  a  perfected  being.  The  better,  therefore,  we 
understand  the  evolution  of  the  embryo  to  the  infant,  the  better  shall  we 
be  prepared  to  appreciate  the  evolution  of  the  infant  to  the  cliild  and  of 
the  child  to  the  adult.  It  is  especially  important  to  understand  the  stage 
of  development  Avhich  exists  just  before  birth,  for  on  this  depends  the 
knowledge  whether  we  have  a  physiologically  and  anatomically  normal 
being  before  us,  or  one  that  is  abnormal.  Disease  does  not  merely  mean 
a  pathological  change  in  the  tissues,  but,  as  is  especially  well  exemplified 
in  the  infant,  may  sinlply  mean  a  retardation  or  arrest  of  development. 
Thus,  what  would  be  perfectly  normal  anatomically  at  the  seventh  month 
of  intra-uterine  life  may  at  birth  be  abnormal,  and  hence  constitute  a 


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THE   FCETAL    CIRCULATION.  19 

disease.  In  like  manner  what  jiiay  be  normal  at  birth  may  if  it  persists 
into  the  second  and  third  weeks  become  an  abnormal  condition.  Disease, 
therefore,  is  a  relative  term.  We  may,  however,  simplify  our  classifica- 
tion of  diseases  by  adopting  two  broad  divisions  corresponding  to  the 
changes  which  take  place  during  intra-  and  extra-uterine  hfe  and  desig- 
nated as  congenital  and  acquired.  By  congenital  diseases  we  mean  those 
resulting  from  changes  occurring  during  intra-uterine  life.  These  may 
arise  from  an  arrest  of  development  or  from  a  continuation  of  normal 
intra-uterine  conditions  beyond  the  usual  period  of  their  cessation ;  also 
those  which  are  caused  by  pathological  processes  such  as  inflammation. 
By  acquired,  we  mean  a  pathological  condition  of  existing  tissues  occur- 
ring after  birth,  and  Avithout  regard  to  the  stage  of  development. 

If  we  thoroughly  understand  the  anatomical  conditions  existing  just 
before  birth,  we  can  intelligently  examine  the  young  human  being  as  it 
emerges  from  the  uterus,  and  can  judge  in  the  early  days  of  its  existence 
whether  we  have  under  our  care  a  normal  infant  or  one  that  is  to  need 
special  treatment. 

II.    THE  FOETAL  CIRCULATION. 

The  chief  anatomical  change  which  takes  place  at  birth  is  the  transi- 
tion from  the  intra-uterine  circulatory  mechanism  to  a  form  adapted  to 
extra-uterine  life ;  in  other  words,  from  the  oxygenation  of  the  blood 
through  the  placenta  to  the  same  process  carried  on  by  the  lungs.  A 
general  knowledge  of  the  foetal  circulation  is,  then,  evidently  of  consider- 
able importance,  especially  when  it  is  considered  that  a  large  proportion 
of  the  cases  of  congenital  heart  disease  which  we  are  called  upon  to 
diagnosticate  is  represented  by  perfectly  normal  prenatal  conditions,  such 
as  absence  of  the  ventricular  septum,  an  open  ductus  arteriosus,  or  a 
patent  foramen  ovale. 

Fig.  1  represents  the  course  of  the  (red)  oxygenated  blood  from  the 
placenta  to  the  infant,  and  that  of  the  darker  (blue)  deoxidized  blood 
from  the  infant  back  to  the  placenta.  We  must  consider  that  in  the  foetus 
the  lungs  are  in  a  collapsed,  inert  condition,  performing  no  part  in  the 
foetal  economy,  but  remaining  quiescent  until  called  upon  to  perform  their 
special  function  at  birih.  The  true  lung  of  the  foetus,  therefore,  is  repre- 
sented by  the  placenta  of  the  mother.  It  is  here  that  the  blood  is  oxygen- 
ated, and  is  carried  by  means  of  the  umbilical  vein  directly  through  the 
umbilicus  of  the  foetus  to  the  liver,  as  seen  in  the  diagram.  In  the  liver, 
the  umbilical  vein  divides  into  three  branches  :  (1)  the  smallest,  carries 
the  blood  directly  to  the  liver  tissue,  whence  it  is  returned  as  in  the  adult 
to  the  inferior  cava  by  the  hepatic  veins ;  (2)  the  largest  portion  meets 
and  mixes  with  the  blood  from  the  portal  system,  and  is  distributed  with 
it  to  the  liver ;  (3)  the  remaining  portion  is  carried,  by  a  vessel  called  the 
ductus  venosus,  directly  to  the  inferior  cava,  where  it  meets  the  deoxidized 
blood  from  the  lower  extremities,  mixes  with  it,  and  is  carried  to  the  right 


20 


PEDIATRICS. 


Fig.  2. 


auricle :  here,  instead  of  passing  as  in  the  adult  into  the  right  ventricle,  it 
is  directed  by  a  membrane,  called  the  Eustachian  valve,  through  an  opening 
between  the  two  auricles,  called  the  foramen  ovale,  into  the  left  auricle. 
It  then  passes  into  the  left  ventricle  through  tlie  mitral  orifice,  and  thence 
through  the  aortic  orifice  into  the  aorta.  The  greater  part  of  the  blood- 
current  is  then  carried  by  the  carotid  and  subclavian  arteries  to  the  head 
and  upper  extremities,  where,  after  doing  its.  work  in  vitalizing  the  tissues 
and  taking  up  their  Avaste  (a  small  portion  also  passing,  as  usual,  into  the 
descending  aorta),  it  is  returned  as  deoxidized  blood  through  the  veins  to  the 
superior  cava  hito  the  right  auricle,  thence  through  the  tricuspid  orifice  into 
the  right  ventricle,  and  up  through  the  pulmonary  artery,  where  a  small 
portion  is  distributed  as  usual  to  the  lungs,  while  the  remaining  portion  is 
carried  directly  over  to  the  descending  aorta  by  a  vessel  called  the  ductus 
arteriosus.  It  here  mixes  with  the  small  portion  of  oxygenated  aortic 
blood  mentioned  above,  and  passes  down  the  aorta,  being  distributed  on 
its  way,  as  in  the  adult,  until  it  reaches  the  internal  iliac  arteries.  From 
these  arteries  it  is  carried,  by  branches  called  the  umbilical  arteries,  through 
the  umbilicus  back  to  the  cord  and  placenta.     Thus,  by  simply  referring 

to  this  diagram,  we  can  tell  at  a  glance 
which  part  of  the  young  infant  should  be 
most  developed,  and  the  reasons  for  it. 
A  noticeable  point  of  clinical  interest,  in 
tracing  the  course  of  the  foetal  circulation, 
is  that  the  fresh  oxygenated  blood  is  mainly 
carried  to  the  liver,  head,  and  upper  ex- 
tremities, while  the  devitalized  blood  is 
distributed  to  the  thorax  and  lower  ex- 
tremities. We  should  therefore  expect, 
and  we  shall  find  it  to  be  true,  when  we 
examine  a  normal  new-born  infant,  that 
the  head  is  larger  than  the  thorax,  that 
the  abdomen  is  prominent  from  con- 
taining the  large  liver,  and  that  the 
legs  are  insignificant  and  poorly  devel- 
oped. 

When  the  placental  circulation  is  cut 
off,  an  increased  amount  of  blood  is  carried 
by  the  pulmonary  artery  to  the  lungs,  and 
by  degrees  the  foetal  circulation  is  replaced 
by  that  of  extra-uterine  life. 
The  ductus  venosus  and  ductus  arteriosus  become  fibrous  cords. 
The  Eustachian  valve  disappears. 
The  foramen  ovale  closes. 

The   umbilical  vein  and  umbilical  arteries  become  obliterated,  with  the 
exception  of  the  lower  parts  of  the  latter. 


Heart,  natural  size,  at  two  days.  A 
marks  tlie  aorta ;  PA  marks  the  pulmo- 
nary artery  ;  DA  marks  the  ductus  arteri- 
osus. 


THE   INFANT   AT  TERM.  21 

During  the  first  two  weeks  of  infancy  we  may  have  conditions  exist- 
ing physiologically  wliich  after  that  time  would  become  pathological,  and 
hence,  to  be  well  grounded  in  the  diagnosis  of  disease  in  the  infant,  we 
must  appreciate  the  importance  of  these  facts. 

Fig.  2  represents  a  heart  taken  from  an  infant  two  days  old.  It  is  of 
natural  size,  and  shows  the  ductus  arteriosus  connecting  the  aortic  and 
pulmonary  arteries. 

III.    THE  INFANT  AT  TERM. 

By  the  infant  at  term  we  mean  one  that  has  been  born  at  the  termina- 
tion of  what  is  considered  the  usual  period  of  pregnancy,  two  hundred 
and  eighty  days. 

SKIN. — A  normally  developed  foetus  when  it  first  emerges  from  the 
uterus  has  a  reddened  skin  and  is  covered  thickly  in  many  parts  by  a 
substance  made  up  of  the  contents  of  the  amniotic  sac,  in  which  the 
foetus  has  been  floating,  and  of  the  excretion  of  the  sebaceous  glands. 
This  substance  is  called  the  vernix  caseosa.  In  certain  rare  cases  also 
this  sebaceous  matter  is  so  universal  and  so  impenetrable  as  to  constitute 
a  disease  of  serious  import,  and  at  times  even  to  cause  death.  Infants 
also  may  be  born  with  the  skin  almost  entirely  free  from  the  vernix  caseosa. 
After  the  infant  has  been  bathed,  and  the  vernix  caseosa  has  been  removed, 
it  should  present  the  color  of  a  healthy  skin  reacting  normally  to  its  external 
surroundings.     The  skin  should  usually  be  some  shade  of  delicate  pink. 

General  Description. — The  body  and  limbs  should  be  well  rounded, 
the  cry  vigorous,  the  extremities  warm,  and  the  grasp  of  the  hands  strong 
and  active.  The  hair  at  birth  is  often  thick,  dark,  and  quite  long,  perhaps 
2  to  5  cm.  (1  to  2  inches),  but  we  also  frequently  find  the  hair  to  be  short, 
fine,  some  shade  of  light  brown,  small  in  amount,  and  the  temples  bald,  the 
hair  coming  down  to  a  round  point  on  the  forehead.  The  eyes  are  almost 
always  half  open  when  awake,  expressionless,  and  of  a  dull  grayish  blue. 
Tlie  head  is  large  in  comparison  with  the  thorax^  the  arms  more  rounded 
and  large  in  proportion  to  the  legs,  and  the  abdomen  is  prominent. 

The  cord  dries  up  and  falls  off  at  about  the  sixth  or  seventh  day. 
It  is  important  to  know  how  it  should  look  normally  up  to  the  day  Avhen 
it  separates  from  the  umbilicus  in  order  to  distinguish  it  from  abnormal 
conditions.  There  is  a  slightly  reddened  areola  where  it  joins  and  is  to 
part  from  the  abdominal  wall.     (Plate  III.) 

Palpation,  percussion,  and  auscultation  show  that  the  heart  has  about 
the  same  proportionate  position  in  reference  to  the  lungs  as  is  found  in 
the  adult,  but  that  the  liver  occupies  much  more  space,  coming  fully  1  to 
2  cm.  (I  to  1  inch)  below  the  edge  of  the  ribs  in  the  right  hypochondriac 
and  the  epigastric  regions,  and  encroaching  on  the  lung-space  in  the  right 
back  to  the  extent  of  fully  one  rib  and  interspace.  The  testicles  have  de- 
scended, and  the  bladder,  when  full  of  urine,  presents  an  area  of  dulness 
of  about  2  cm.  (1  inch)  just  above  the  pubis  in  the  median  line.     It  is  an 


22  PEDIATRICS. 

important  fact  that  the  bladder  is  an  abdominal  rather  than  a  pelvic  oi^an 
in  the  infant  and  young  child.  The  dull  area  of  the  spleen  corresponds 
in  its  position  to  that  found  in  the  adult,  but  is  scarcely  perceptible. 

The  following  anatomical  and  physiological  truths  relating  to  the  hifant 
at  term  are  based  on  what  is  usually  found  to  exist  in  the  average  infant. 
We  are  especially  indebted  to  Professor  Thomas  Dwight  for  the  assistance 
which  he  has  given  to  us  from  his  own  original  investigations,  and  from 
his  verification  of  the  anatomical  part  of  the  work.  It  has  not  been  at- 
tempted to  give  the  complete  anatomy  and  physiology  of  the  various 
periods  of  early  life,  but  merely  to  pick  out  the  practical  points  in  these 
periods  which  will  aid  in  clinical  diagnosis  and  treatment.  The  great 
importance  of  thoroughly  understanding  the  normal  anatomy  and  physi- 
ology of  human  beings  before  attempting  to  deal  with  the  morbid  condi- 
tions which  arise  in  them  is  now  so  well  recognized  that  no  preliminary 
remarks  are  needed  to  show  how  vital  to  all  advance  m  clinical  medicine 
is  the  proper  reading  of  anatomical  and  physiological  truths.  There  are 
several  pomts  in  the  anatomy  and  physiology  of  the  new-born  infant  which 
would  be  better  understood  if  the  fact  were  borne  m  mind  that  in  many 
respects  the  body  at  this  age  is  more  adapted  to  its  intra-uterine  life  and 
to  its  means  of  exit  into  the  external  world  than  to  the  conditions  which 
surround  it  in  extra-uterine  life. 

It  is  not  uncommon  at  birth  for  the  face  to  be  swollen  and  the  features 
out  of  shape ;  this  comes  from  pressure,  and  will  soon  pass  away. 

At  birth  the  trunk  is  egg-shaped,  the  larger  end  being  below.  The 
pelvis  as  a  region  hardly  exists,  and  the  thorax  is  very  small  when  com- 
pared with  the  large  abdomen.  The  latter  is  very  large,  owing  to  the 
disproportionate  development  of  the  liver,  presumably  a  great  organ  of 
nutrition  during  foetal  life.  A  strikmg  peculiarity  is  the  almost  complete 
absence  of  shoulders,  which  mth  the  arms  are  relatively  insignificant  out- 
groA^ihs  from  the  sharp  end  of  the  e^.  It  is  e\adent  that  the  small  size 
of  the  thorax,  its  Avant  of  solidity,  and  the  slight  development  of  the 
pectoral  and  shoulder  muscles  indicate  that  its  action  in  respiration  must 
be  very  different  from  that  in  adult  life. 

The  greatest  breadth  of  the  trunk  is  in  the  region  of  the  lower  ribs. 

During  intra-uterine  life,  and  especially  at  the  time  of  delivery,  great 
flexibility  and  compressibihty  are  requisite.  Respiration  has  not  yet  oc- 
curred, and  the  assimilation  of  nutriment  for  the  growth  of  the  body  and 
for  preparing  the  rudiments  of  future  organs  has  been  the  function  most 
actively  employed.  AMien,  therefore,  we  study  the  new-born  infant,  we 
must  remember  that  we  see  it  at  an  essentially  transitional  stage.  Adap- 
tations, the  marked  utility  of  Avhich  is  past,  still  persist,  and  new  func- 
tions are  carried  on  with  very  imperfect  apparatus. 

SPINE. — At  birth  the  spine  consists  of  little  bone  and  much  cartilage 
and  fibrous  tissue.  It  can  be  twisted  and  bent  at  will  in  any  direction. 
It  appears  relatively  broader  in  proportion  to  its  length  than  does  the 


THE   INFANT   AT   TERM. 


23 


adult  spine.  The  height  of  the  vertebrae  is  relatively  less,  and  appears 
even  less  than  it  is,  from  the  fact  that  the  broad,  narrow,  bony  nucleus 
of  the  vertebral  body,  which  catches  the  eye,  does  not  represent  the  whole 
thickness  of  the  body,  as  it  is  embedded  in  cartilage. 

At  this  early  stage  of  development  the  whole  column  is  cartilaginous, 
A^ith  the  exception  of  the  nuclei  of  the  bodies  of  the  vertebrEe  and  those 
of  the  laminae  on  either  side,  forming  a  small  portion  of  the  body  and 


Infant  at  birth. 


Fig.  3. 
SPINAL   CURVES. 
Infant  sitting. 


Infant  standing. 


Front     — •• 


D 


D 


(2)  (3) 

C  represents  cervical  curve ;  D  represents  dorsal  curve ;  L  represents  lumbar  curve ;  S  represents 

sacral  curve. 


the  beginning  of  the  arch.     The  time  of  the  consolidation  of  the  bodies 
is  not  accurately  known. 

In  the  young  embryo,  the  proportion  of  the  neck  in  the  movable  part  of 
the  spine  is  greater  than  that  of  the  loins,  a  condition  which  is  reversed 
in  the  adult,  where  the  neck  is  less,  being  a  little  over  one-fifth,  and  the 
loins  a  little  less  than  one-third.  In  fact,  the  proportions  of  the  spine 
change  considerably  from  an  early  period  of  intra-uterine  life  to  that  of 
the  perfected  adult  condition.     At  birth,  ho^vever,  the  change  has  pro- 


24  PEDIATRICS. 

gressed  sufficiently  to  make  these  two  parts  very  nearly  equal.  The 
union  of  the  lamiuEP  to  form  the  spine  begins  in  the  upper  part  of  the 
spine  sooner  than  in  the  lumbar  region.  Throughout  the  greater  part 
they  are  nearly  united,  and  in  some  places  are  quite  joined,  at  birth. 

Fig.  3  represents  (1)  the  natural  curve  at  birth,  (2)  the  curve  which 
comes  especially  in  the  cervical  region  when  the  infant  has  learned  to  sit 
up  and  the  superincumbent  head  has  to  be  supported,  and  (3)  the  addi- 
tional dorsal  and  increased  lumbar  curves  which  appear  when  the  child 
stands  and  walks,  and  which  correspond  to  those  of  the  adult  condition. 

At  birth,  when  the  child  is  lying  in  what  may  be  called  its  normal 
position. — that  is  to  say,  on  its  side,  with  the  head  flexed  and  the  thighs 
drawn  up, — the  whole  spinal  column  jn-esents  one  long  concavity  from 
the  atlas  to  the  coccyx,  the  front  of  which  is  subdi\ided  into  two  curves 
by  the  slight  projection  of  the  promontory  of  the  sacrum.  Above  this 
there  is  a  tolerably  regular  concavity.  The  head  can  be  thrown  back  so 
as  to  make  a  slight  convexity  in  the  neck,  and  by  bringing  the  knees 
against  the  table  (the  infant  being  on  its  back)  the  lumbar  region  will 
spring  forward  ;  but  the  former  of  these  positions  is  rather  unnatural,  and 
the  latter  impossible  without  assistance.  "We  can  then  consider  the  part 
of  the  spine  above  the  sacrum  as  essentially  a  fibrous  and  cartilaginous 
rod,  with  a  number  of  separate  disks  of  bone  embedded  in  it  at  different 
places.  The  extent  of  the  movements  possible  at  birth,  both  in  the  dis- 
sected spine  and  in  the  whole  body,  is  remarkaJDle. 

At  all  ages,  from  birth  upward,  the  spine  of  the  fourth  lumbar  verte- 
bra is  (as  in  the  adult)  on  a  level  with  the  highest  point  of  the  crest  of 
the  ilium  (Dwight).  Under  certain  circumstances  this  might  advanta- 
geously be  used  as  a  starting-point  from  which  to  count.  At  birth  the 
spinal  cord  descends  only  the  space  of  alDOut  one  vertebra  lower  than  in 
the  adult.  The  third  lumbar  spine,  which  should  mark  its  termination, 
cannot  be  easily  recognized  under  three  years,  but  the  correspondence  of 
the  top  of  the  ilium  with  the  fourth  A^ertebral  spine  allows  its  position  to 
be  estimated.  It  is  desirable  to  know-  how  far  the  caLxiiy  of  the  spinal 
dura  mater  descends  inside  the  sacrum.  Recent  investigations  by  Wagner 
show  that  in  cliildren  under  a  year  old  it  ends  usually  near  the  top  of  the 
third  sacral  vertebra,  which  makes.it  a  little  lower  than  its  usual  termina- 
tion in  the  adult.  The  point  on  the  surface  corfesponding  to  this  could 
be  approximately  estimated  without  any  definite  landmarks. 

NECK. — It  is  customary  to  say  that  young  babies  have  no  necks  ;  and 
yet  when  speaking  of  the  spine  it  was  stated  that  the  cervical  region  of 
the  vertebral  column  of  the  infant  and  young  child  is  relatively  longer 
than  in  the  adult.  From  this  point  of  view  the  shortness  of  the  infant's 
neck  must  be  seeming  rather  than  real,  but  from  a  clinical  stand-point  it 
is  real  enough.  The  causes  of  the  short  neck  are,  first,  the  large  head, 
wliich  naturally  falls  forward,  covering  the  upper  portion,  and  next,  the 
high  position  of  the  sternum  encroaching  on  it  from  below.     The  large 


THE    INFANT    AT    TERM. 


25 


proportion  of  subcutaneous  fat  tends  to  make  the  neck  appear  still 
shorter. 

The  larynx  is  at  first  placed  much  higher  than  later  (Symington). 
In  the  adult  the  lower  border  of  the  cricoid  is  about  on  a  level  with  the 
top  of  the  seventh  vertebra.  In  the  infant  it  usually  seems  to  be  near  the 
lower  border  of  the  fourth  vertebra. 

HEAD. — Young  infants  frequently  have  at  birth  a  startling  shape  to 
their  heads  produced  by  pressure.  One  side  of  the  skull  may  be  flattened, 
while  the  other  bulges,   or  the  natural  diameters  of  the  head  may  be 

Fig.  4. 


Skull  of  infant  at  term,  natural  size.    Posterior  view,  showing  parietal  and  occipital  bones  and  jKisterior 
fontanelle.    AVarren  Museum,  Harvard  University. 

altered,  presenting  a  long,  narrow  head  instead  of  a  round,  well-formed 
cranium.  These  shapes  at  times  give  an  idiotic  expression  to  the  infant 
which  causes  much  distress  to  the  parents.  In  almost  every  case  these 
abnormal  appearances  pass  away  in  a  few  months,  as  the  skull  and  brain 
grow,  and  do  not.  as  a  rule,  indicate  disease  unless  very  extreme,  so  that 
it  is  well  to  state  this  fact  to  parents  at  once  and  thus  to  relieve  their 
minds.  As  a  rule,  if  the  measurements  of  the  head  are  taken  over  the 
middle  of  the  forehead  and  around  to  the  occipital  protuberance,  it  will  be 
found  that  at  birth  the  circumference  is  about  33  cm.  (13  inches). 

FoNTANELLES. — ^The  Opening  between  the  frontal  bones  and  the  anterior 
borders  of  the  parietal  bones  is  called  the  anterior  fontanelle.  and.  though 


26  I'EDIA'rRTOS. 

somewhat  depressed  below  the  level  of  the  hones  at  first,  should  soon  be 
about  on  a  level  with  them.  Its  size  is  variable,  but  is  usually  about  2  to 
3  cm.  (I  to  1  -|-  inches)  long,  and  about  2  cm.  (|  inch)  wide.  In  the  early 
days  and  even  weeks  of  infancy  the  frontal  suture  is  usually  open  in  its 
upper  part,  as  shown  in  Fig.  26,  facing  page  82. 

The  opening  between  the  occipital  bone  and  the  posterior  edges  of  the 
parietal  bones  is  much  smaller,  is  of  less  significance  than  the  anterior 
opening,  is  often  temporarily  obliterated  by  the  overlapping  of  the  bones, 
and  is  called  the  posterior  fontanelle. 

Face  and  Cranium. — In  infants  the  proportion  of  the  face  to  the  cra- 
nium is  strikingly  different  from  what  is  found  in  adults,  where  it  is  as  one 
to  two,  while  according  to  Froriep  the  face  in  the  infant  is  to  the  skull  as 
one  to  eight. 

If  the  front  view  of  the  face  and  cranium  of  the  infant  and  of  the 
adult  is  contrasted  by  counting  as  face  all  below  a  line  at  the  tops  of  the 
orbital  arches,  and  as  skull  all  that  is  seen  above  that  line,  considering  it 
projected  on  a  vertical  plane  as  in  a  photograph,  it  will  be  found  that  in 
the  infant  the  skull  forms  about  one-half,  and  in  the  adult  much  less. 

The  height  of  the  orbit  bears  pretty  nearly  the  same  proportion  to  the 
skull  at  all  ages,  except  that  it  equals  barely  a  third  of  the  adult  face, 
while  it  makes  nearly  a  half  of  it  at  birth.  While  the  top  of  the  nasal 
opening  retains  pretty  nearly  the  same  relation  to  the  orbit  at  all  ages,  its 
lower  border  is  but  very  little  below  the  lowest  point  of  the  orbit  at  birth, 
while  it  is  much  below  it  in  the  adult.  In  the  latter,  a  line  connecting 
the  lowest  points  of  the  malar  bones  crosses  the  nasal  cavity,  or  at  least 
touches  its  lower  border,  while  in  the  infant  it  runs  almost  half-way  be- 
tween the  lower  border  and  the  edge  of  the  alveolar  process.  The 
breadth  of  the  skull  in  its  greatest  diameter  in  the  infant  equals,  or  even 
exceeds,  the  total  height  of  the  skull  and  the  face,  while  in  the  adult  it  is 
but  about  three-quarters  of  it.  Still  more  striking  is  the  difference  be- 
tween the  length  and  the  breadth  of  the  face  at  different  stages.  The 
breadth,  measured  between  the  most  distant  points  of  the  zygomata,  is  to 
the  height  of  the  face  in  the  adult  about  as  nine  to  eight,  while  at  birth  it 
is  perhaps  as  much  as  ten  to  four. 

The  side  view  is  equally  or  even  more  characteristic.  The  auditory 
meatus  is  situated  about  midway  between  the  front  and  the  back  in  the 
infant,  but  in  the  adult  it  is  decidedly  behind  the  middle.  The  face  appears 
to  be  but  an  insignificant  part  of  the  w^hole  structure. 

Jaws. — The  lower  jaw  is  almost  on  the  same  plane  as  the  mastoid 
process  of  the  temporal  bone,  and  the  upper  border  of  the  zygoma  is 
about  on  a  level  with  the  floor  of  the  nasal  cavity,  while  in  the  adult  it  is 
at  or  near  the  level  of  the  floor  of  the  orbit.  It  is  evident  that  a  very 
important  factor  in  the  adult  face  is  the  development  of  the  jaws  and  of 
the  teeth,  and  that  it  is  due  to  their  rudimentary  condition  that  the  face  is 
so  small  in  infancy.    The  difference  in  the  comparative  development  of  the 


THE   INFANT   AT   TERM.  27 

lower  jaw  at  birth  and  at  three  years  is  well  exemplified  by  the  skulls 
shown  in  Fig.  12,  page  48. 

Gums. — The  gums  do  not  meet  in  the  new-born  (McClellan).  They 
are  composed  of  a  dense  fibrous  tissue  covered  by  vascular  mucous  mem- 
brane of  very  slight  sensibility,  and  are  protective  to  the  groAving  teeth. 

Naso-pharynx. — A  median  section  of  an  infant's  head  shows  very 
strikingly  the  want  of  height  of  the  naso-pharynx  and  the  great  obliquity 
(approaching  the  horizontal)  of  the  posterior  edge  of  the  vomer.  The 
naso-pharynx  is  relatively  very  long  from  before  backward.  Strange  as 
it  may  seem,  the  distance  from  the  back  of  the  hard  palate  to  the  soft 
parts  of  the  back  of  the  pharynx  (excluding  the  tonsil)  is  about  as  great 
at  birth  as  in  the  adult.  A  knowledge  of  the  change  in  size  and  shape  of 
the  nasal  cavities  and  naso-pharynx  in  the  course  of  growth  is  very  impor- 
tant. The  nasal  cavity  consists  of  an  upper  olfactory  region,  occupying 
the  ethmoidal  portion  of  the  cavity,  and  a  lower  respiratory  region  occu- 
pying the  maxillary  part.  In  the  infant  the  nasal  cavity  is  relatively  long 
and  shallow,  and  the  respiratory  portion  is  very  narrow. 

The  height  of  the  posterior  nares  at  birth  is  6  to  7  mm.,  and  the 
breadth  between  the  pterygoid  processes  at  the  hard  palate  is  9  mm. 
(D  wight.) 

In  the  infant  the  naso-pharynx  is  simply  a  narrow  passage  running 
obliquely  backward  and  downward  from  "the  constricted  opening  of  the 
posterior  nares.  The  soft  palate  of  the  child  is  placed  more  horizontally 
than  in  the  adult.  The  posterior  nares  (not  the  inferior  meatus  alone, 
but  the  whole  opening  on  either  side)  is  just  large  enough  to  admit  the 
end  of  a  medium-sized  male  catheter;  this  leads  into  the  passage  just 
mentioned,  and  therefore  a  congestion  of  the  nasal  mucous  membrane  in 
infancy,  Avith  the  addition  of  the  mucous  secretion,  may  effectually  close 
the  opening  from  the  nose  to  the  pharynx. 

It  IS,  perhaps,  not  sufficiently  recognized  clinically  how  important  a 
function  is  performed  by  the  nasal  passages  in  early  infancy, — far  more 
important,  indeed,  than  at  any  other  age.  In  fact,  the  age  of  the  infant 
is  in  inverse  ratio  to  the  dangers  which  may  arise  from  obstruction  of  the 
nares. 

These  dangers,  consequent  on  obstruction,  congestion,  and  the  result- 
ing mechanical  disturbance  of  neighboring  parts,  thus  leading  to  actual 
disease  of  those  parts,  become  in  the  new-born  infant  of  most  serious  and 
even  vital  import.  We  have  seen  an  infant  die  of  simple  acute  nasal  catarrh 
in  the  first  two  or  three  days  of  life.  In  this  case  the  infant  was,  indeed, 
puny  and  ill  cared  for. 

There  is  no  doubt  that,  with  due  appreciation  of  the  value  of  the 
nasal  function  and  the  danger  of  allowing  it  to  be  interfered  with,  we  can, 
as  a  rule,  even  in  extremely  weak  infants,  prevent  a  fatal  result. 

Lymph- Vessels  of  the  Pharynx. — ^An  anatomical  condition  of  great 
importance  is  that  in  comparison  with  the  faucial  tonsils,  which  are  rela- 


28  PEDIATRICS. 

lively  poor  in  absorbents,  an  exceedingly  rich  plexus  of  absorbents  exists 
in  the  posterior  wall  of  the  naso-pharynx. 

Eustachian  Tubes. — In  the  foetus  the  nasal  opening  is  below  the  level 
of  the  hard  palate,  which  it  reaches  at  birth.  While  in  the  adult  the  car- 
tilaginous portion  slants  downward,  nevertheless  the  opening  of  the  tube 
is  opposite  a  higher  part  of  the  nose  than  in  the  child.  At  birth  the  tube 
is  horizontal  or  nearly  so.  It  must  be  borne  in  mind  that  even  if  the 
opening  of  the  tube  be  below  the  level  of  the  hard  palate,  the  soft  palate 
none  the  less  runs  beneath  it,  shutting  it  off  from  the  cavity  of  the  mouth 
and  the  passage  from  it  to  the  fauces. 

In  the  infant  and  in  the  young  child  there  is  but  a  slight  development 
of  the  end  of  the  cartilage  which  makes  in  the  adult  so  prominent  a  fold 
at  the  back  of  the  pharyngeal  opening  of  the  tube,  and  by  its  prominence 
does  much  to  determine  the  depth  of  the  fossa  of  Rosenmiiller,  the  recess 
behind  it  at  the  lateral  posterior  angles  of  the  pharynx.  At  birth  this 
prominence  hardly  exists.  The  opening  of  the  tube  is  at  first  very  small. 
That  the  catheterization  of  the  tube  at  this  age  presents  great  difficulties  of 
its  own,  apart  from  the  intractability  of  the  patient,  is  sufficiently  obvious. 

The  tube  in  infancy,  while  of  course  shorter  than  in  the  adult,  is  stated 
to  be  not  only  relatively,  but  absolutely,  wider  at  its  narrowest  point, 
Avhich  may  explain  the  case  with  which  catarrhal  processes  travel  at  that 
age  to  the  middle  ear. 

Faucial  Tonsils — Pharyng-eal  Tonsil — Lymphoid  Tissue. — The 
faucial  tonsils,  the  pharyngeal  tonsil,  the  lymphoid  masses  under  the 
mucous  membrane  of  the  posterior  third  of  the  tongue,  the  lymphoid 
tissue  about  the  orifices  of  the  Eustachian  tubes,  to  say  nothing  of  irregu- 
lar aggregations  of  the  same  tissue  in  the  neigliborhood,  form  a  lymphoid 
ring  around  the  pharynx  which  is  most  important.  It  is  to  be  noticed 
that  the  passage  from  the  nose,  as  well  as  that  from  the  mouth,  is  guarded 
by  this  apparatus.  That  its  function  is  in  part  protective  seems  very 
probable,  in  spite  of  the  fact  that  when  hypertrophied  it  gives  rise  to 
serious  trouble.  Before  birth  this  system  is  but  slightly  developed.  In- 
deed, the  follicles  at  the  back  of  the  tongue  are  not  always  to  be  found  at 
that  time. 

A  pocket  in  the  pharyngeal  tonsil  is  the  famous  bursa  pharyngea.  It 
is  clinically  important  merely  as  a  recess  in  which  inflammation  may 
linger  and  secretions  be  retained. 

The  supposition  that  this  system  is  protective  receives  support  from 
Killian^s  observation  that  the  pharyngeal  tonsil  is  much  developed  in 
mammals  that  live  in  the  dust  of  houses.  It  is  not  impossible  that  this 
lymphatic  ring  forms  a  bulwark  against  septic  invasion. 

Goodale's  investigations  show  that  bacteria  are  found  in  the  tonsillar 
crypts  and  that  such  organisms  may  be  absorbed  in  the  gland,  but  as  soon 
as  absorbed  they  meet  with  such  conditions  as  would  be  likely  to  termi- 
nate their  life.     The  small  size  of  the  naso-pharynx  in  the  mfant  and  the 


THE    INFANT    AT   TERM.  29 

young  child  explains  its  obliteration  by  the  enlargement  of  the  pliaryngeal 
tonsil. 

Mouth. — The  mouth,  as  a  whole,  is  pre-eminently  an  organ  intended 
for  the  reception  of  a  liquid  food,  its  mechanism  being  that  of  suction. 
It  is  a  natural  and  necessary  passage-way  to  the  organs  of  digestion,  but 
is  not  at  first  intended  to'  aid  the  digestion  by  a  salivary  secretion. 

Tongue. — The  tongue  at  birth  is  slightly  coated  and  comparatively 
dry.  It  is  greatly  wanting  in  vertical  thickness,  and  on  section  is  shown  to 
be  long  and  narrow.  The  soft  palate,  therefore,  rests  on  the  tongue,  and, 
the  mouth  being  closed,  runs  in  the  main  backward,  descending  very  much 
less  than  in  the  adult.  The  uvula  is  rudimentary  (Merkel).  Owing  to 
the  depth  of  the  pharynx  (from  before  backward),  the  soft  palate  is  unable 
to  shut  off  the  passage  to  the  naso-pharynx  as  completely  in  early  infancy 
as  subsequently. 

Teeth. — At  birth  there  are  twenty  embryo  teetli,  ten  in  each  jaw,  en- 
veloped in  their  respective  tooth-sacs,  protected  above  by  the  submucous 
tissue  and  mucous  membrane,  on  either  side  by  alveolar  bone-substance, 
and  below  by  the  groove  in  the  maxillary  bone  from  which  the  alveoli 
have  developed. 

Hard  Palate. — At  birth  and  in  the  early  months  of  life  the  line  of 
the  hard  palate,  continued  backward,  strikes  near  the  top  of  the  basi- 
occipital,  that  is,  near  its  junction  with  the  sphenoid,  or  perhaps  even 
strikes  the  latter.  Accordingly,  at  this  age,  if  the  finger  be  introduced 
directly  backward  through  the  mouth,  pushing  the  soft  palate  upward,  it 
will  strike  the  occipital  bone,  and  being  carried  a  little  downward,  will 
pass  over  the  arch  of  the  atlas,  the  base  of  the  odontoid,  and  the  body 
proper  of  the  axis.  Going  still  lower,  the  top  of  the  third  cervical  verte- 
bra might  be  felt,  but  the  larynx  would  hardly  permit  the  finger  to  go 
lower,  and  the  parts  are  so  small  that  it  is  questionable  if  much  could  be 
recognized  below  the  axis. 

Brain. — The  brain  of  the  new-born  infant  is  proportionately  very  much 
larger  than  in  the  adult,  bearing  a  relation  of  about  15  to  1.     (Vierordt.) 

Eye. — The  eye  is  anatomically  perfectly  developed  in  the  new-born. 
(McClellan.) 

Ear. — The  development  of  the  ear  is  in  its  several  parts  very  unequal 
(McClellan).  The  structures  of  the  internal  ear,  the  tympanic  cavity,  and 
the  auditory  ossicles  are  fully  formed  at  birth,  while  the  external  auditory 
meatus,  the  Eustachian  tube,  and  the  mastoid  portion  of  the  temporal 
bone  undergo  many  modifications  before  their  full  development  at  puberty. 
At  birth  the  meatus  passes  inward  and  inclines  downward,  and  the  mem- 
brana  tympani  is  almost  horizontal,  conditions  to  be  remembered  as 
necessitating  a  little  different  management  of  the  ear  speculum  from  what 
is  taught  in  the  examination  of  the  adult  ear. 

The  mastoid  antrum  exists  at  birth,  but  the  cells  do  not  develop  until 
later. 


30  PEDIATRICS. 

Petro-Squamosal  Suture. — An  important  auatoniical  condition  exist- 
ing at  birth  is,  that  the  petro-squamosal  suture  is  open,  allowing  a  close  con- 
nection betAveen  the  blood-vessels  of  the  brain  and  the  middle  ear,  with 
its  resulting  clinical  significance. 

THORAX. — The  thorax  of  the  infant  forms  the  upper  and  smaller 
end  of  the  egg-shaped  body  w^hich  has  been  already  described,  while  the 
small  shoulders  make  the  chest  very  different  from  that  of  the  adult. 
Besides  this,  the  whole  shape  of  the  thorax  is  very  peculiar.  The  pro- 
portion of  the  dorsal  region  of  the  spinal  column  is  pretty  nearly  the 
same  throughout  life,  but  the  thorax  itself  varies  greatly.  At  birth  the 
thorax  is  very  insignificant.  In  front  the  breast-bone  is  relatively  much 
smaller  than  that  of  the  adult  male,  but  not  very  different  from  some 
very  small  breast-bones  which  are  occasionally  met  with  in  women.  The 
lower  part  is,  however,  but  slightly  developed.  The  borders  of  the  rilDs 
diverge  relatively  rapidly.  This  is  perhaps  due  to  the  great  breadth  of 
the  abdomen. 

Top  of  the  Sternum. — The  sides  of  the  thorax  are  not  relatively  so 
long  as  in  the  adult,  which  is  probably  partly  due  to  the  lesser  develop- 
ment of  the  lower  ribs  and  partly  to  the  very  important  characteristic  of 
the  infant's  thorax, — namely,  that  the  top  of  the  sternum  is  placed  higher 
than  in  the  adult.  The  top  of  the  sternum  in  the  latter  is  about  on  a 
level  with  the  disk  between  the  second  and  third  dorsal  vertebra.  The 
top  of  the  sternum,  according  to  Symington,  is  opposite  about  the  middle 
of  the  first  dorsal  vertebra  in  the  new-born  infant,  and  a  frozen  section 
by  Riidinger  shows  it  to  be  rather  below  the  middle  of  the  first. 

Diameters. — Another  most  important  peculiarity  of  the  infantile  and 
child's  thorax  is  its  want  of  breadth.  In  the  adult  throughout  the  thorax, 
from  about  the  level  of  the  second  costal  cartilage,  or  even  a  little  higher, 
to  the  top  of  the  diaphragm,  the  antero-posterior  diameter  of  the  interior 
of  the  thorax  is  to  the  transverse  as  one  to  two  and  a  half  or  one  to  three, 
there  being,  of  course,  a  certain  amount  of  variation.  At  birth,  on  the 
other  hand,  it  is  as  two  to  three. 

It  is  well  knoAvn  that  in  the  infant  the  ribs  are  more  nearly  horizontal 
than  in  adult  life.  A  striking  feature  of  the  young  infant's  chest  is  that  the 
ribs  form  the  sides  of  the  chest,  and  the  sternum  and  cartilages  the  front. 

Ossification. — At  birth  the  sternum  is  practically  a  strip  of  cartilage 
in  which  a  varying  number  of  bone-centres  have  been  deposited.  There 
is  one  for  the  manubrium  and  usually  one  or  two  for  the  second  and 
third  pieces,  those  for  the  latter  being  very  frequently  double.  These, 
however,  are  mere  thickenings  of  the  cartilaginous  strip,  which  is  flexible 
and  pliable  m  all  du-ections.  (Figs.  26  and  27,  facing  page  82,  shoAv  these 
divisions  of  the  sternum.) 

Respiration, — An  important  feature  in  the  mechanism  of  thoracic  res- 
piration is  the  rigidity  of  the  thorax.  In  the  infant  at  birth  this  rigidity 
is  almost  wholly  absent,  as  it  is  found  only  in  the  libs. 


THE   INFANT   AT   TERM.  31 

The  sternum  is  at  this  age  practically  a  perfectly  flexible  strip  of  carti- 
lage, for  the  small  points  of  ossification  in  it  only  modify  the  softness  of 
certain  separate  parts.  The  dorsal  region  of  the  spine  is  not  fixed  as  a 
concavity,  but  can  be  bent  freely  backward.  The  motions  of  the  ribs  are 
practically  the  same  as  in  the  adult,  but  the  effect  of  these  motions  is 
different.  In  the  first  place,  as  has  been  shown,  the  ribs  are  more  nearly 
horizontal,  and  the  thorax,  even  after  death,  is  in  what  is  called  the  in- 
spiratory condition.  The  nearly  horizontal  first  rib  can  hardly  rise  any 
higher  unless  the  whole  spine  is  bent  backward.  The  ribs,  being  straighter 
than  in  the  adult,  do  not  when  raised  increase  the  breadth  of  the  chest  to 
the  same  degree.  The  nature  of  the  infantile  respiratory  movements  is 
far  from  easy  to  analyze.  Sometimes  it  seems  abdominal  and  sometimes 
thoracic.  The  fact  is,  that  at  first  it  is  of  a  very  indefinite  type.  The 
thorax  seems  to  expand  as  it  can.  It  is  common  to  see  its  lower 
pari  drawn  inw^ard  by  the  contraction  of  the  diaphragm.  At  birih  no 
especial  part  of  the  respiratory  apparatus  has  attained  a  sufficient  develop- 
ment to  insure  its  continuous  equable  action,  and,  as  would  be  expected, 
irregular  respiratory  movements  and  no  decided  type  of  respiration  are 
found. 

A  sufficient  number  of  observations,  however,  have  not  yet  been  made 
to  warrant  our  stating  any  especial  age  at  which  the  type  of  respiration  in 
the  two  sexes  separates  and  the  female  infant  assumes  the  thoracic  type  of 
respiration.  But  if  the  breathing  of  the  infant  is  essentially  irregular  in 
type,  it  is  admirably  adapted  to  the  wants  of  its  age.  The  elastic  thorax 
can  give  way  under  pressure  and  expand  in  almost  any  direction.  The 
flexible  sternum  submits  to  liberties  which  no  adult  breast-bone  would 
endure.  One-half  of  the  chest  may  be  compressed  and  yet  the  other  go 
on  acting  independently. 

The  facts  that  the  top  of  the  sternum  is  higher,  reckoning  from  the 
spine,  that  the  ribs  are  more  nearly  horizontal,  and  that  probably  the 
lower  part  of  the  sternum  is  relatively  less  developed  than  in  the  adult, — 
necessarily  imply  certain  peculiarities  in  the  relations  of  the  internal  parts. 

Diaphragm. — The  diaphragm  rises  highest  on  the  right  over  the  summit 
of  the  liver,  is  a  little  lower  on  the  left,  and  lower  still  at  its  tendinous 
centre  in  the  median  line.  It  is  generally  stated  that  the  diaphragm  is 
higher  in  the  child  than  in  the  adult.  Dwighf  s  observations,  partly  origi- 
nal, partly  on  the  frozen  sections  of  other  writers,  give  the  following  re- 
sults. In  the  infant  the  diaphragm  appears  to  be  opposite  the  disk  between 
the  eighth  and  ninth  dorsal  vertebrte.  In  the  infant  it  appears  as  if  there 
were  a  lower  insertion  of  the  diaphragm  to  the  sternum  and  the  seventh 
costal  cartilages  than  in  the  adult.  Usually  the  line  runs  from  one  costal 
arch  to  the  other,  somewhat  above  the  apex  of  the  ensiform  cartilage, 
leaving,  therefore,  a  space  on  either  side  of  the  latter,  where  the  interior 
of  the  thorax  is  against  the  abdominal  walls.  Owing,  perhaps,  to  the 
greater  flexibility  of  the  body  and  to  the  less  firm  attachment  of  the  in- 


82  PEDIATRICS. 

Icriiul  parts  one  to  iuiotlier,  it  CLTtainly  seems  tliat  at  least  alter  death  the 
thoracic  cavity  is  more  accessible  at  the  sides  of  the  ensiform  than  it  is  in 
the  adult. 

We  may  conclude  that,  while  there  is  some  variation,  on  the  whole, 
the  central  point  of  the  diaphragm  is  in  the  infant  higher  in  relation  to  the 
spin<'  than  later  in  life,  and  that  it  gradually  becomes  lower.  How  high 
the  diaphragm  rises  laterally  is  hard  to  say,  for  it  is  a  point  very  difficult 
to  observe.  According  to  Kb  Hiker,  in  the  foetus  at  term,  on  the  right  it 
reaches  the  level  of  the  anterior  end  of  the  fourth  cartilage,  and  on  the  left 
that  of  the  fourth  iidercostal  space.  Henke  adds  to  this  that  certainly 
after  respiration  has  begun  it  will  never  be  so  high  again. 

TuYMUs  CJla.xd. — The  thymus  gland  exists  at  birth,  and  lies  above  and 
to  some  extent  before  the  heart. 

Heart. — The  most  striking  peculiarity  of  the  infant's  heart  is  that  it  is 
less  covered  by  the  lungs  than  in  adult  life.  Together  with  the  thymus 
gland  it  forms  a  solid  mass  from  the  posterior  mediastinum  to  the  sternum, 
pushing  the  lungs  far  apart.  It  is  to  be  noticed,  however,  that  the  pleural 
cavities  extend  as  far  forward  as  in  the  adult.  The  relations  of  the  heart 
to  the  chest  walls  are  curious  in  the  infant,  for  these  anterior  ^^•alls  are,  as 
already  stated,  high  in  relation  to  the  spine,  yet  the  heart  itself  is  high  in 
relation  to  the  walls.  At  least  the  upper  half  of  it  is  so.  With  regard  to 
the  apex  and  the  lower  borders  the  relations  are  less  certain.  We  usually 
find  the  impulse  of  the  heart  rather  higher  and  nearer  to  the  mammary 
line  in  the  infant  than  in  the  adult.  The  weight  of  the  heart  at  birth  is 
20.6  grammes  (about  f  ounce),  according  to  Boyd,  and  its  proportion  to 
the  rest  of  the  body  is  largest  at  about  the  time  of  birth. 

Common  Carotid  Artery. — The  common  carotid  artery  has  in  the  new- 
born half  the  length  of  the  descending  aorta,  but  this  proportion  is  much 
lessened  at  a  more  advanced  age,  when  the  vertebral  column  increases  in 
length. 

Veins. — According  to  Jacobi,  there  are  one  hundred  valves  in  the  veins 
of  the  lower  extremities  of  the  new-born. 

Pulmonary  Artery. — The  pulmonary  artery  also,  as  stated  by  Jacobi, 
is  from  two  to  four  centimetres  (three-fourths  to  one  and  five-eighths 
inches)  larger  than  the  descending  aorta. 

Lung. — Anatomically  on  the  right  side  the  eleventh  rib  behind  marks 
the  lower  border  of  the  lung,  while  it  descends  as  low  as  the  twelfth  rib  on 
the  lett  side.  In  front  the  lung  extends  to  about  the  fourth  or  fifth  rib  on 
the  right  side  and  the  sixth  rib  on  the  left  side.  The  lung  at  birth  is  charac- 
terized by  its  embryonic  type.  The  infant's  lung  represents  an  interme- 
diate condition  of  growth,  which  illustrates  the  gradual  change  from  the 
foetal  to  the  adult  condition.     (Figs.  5  and  6,  Northrup.) 

According  to  Northrup,  if  we  examine  the  lung  of  a  five  months' 
fcEtus  it  is  found  that  the  bronchi  constitute  the  entire  respiratory  tract 
thus  far  developed.     At  the  terminal  end  of  the  bronchi  there  are  bud- 


Pig.  5. 


ESSE 


^:V"SiSm-  M        /':..,rgSJi 


'^  m. 


..:*: .  .'>i 


si^^liiiis^irtW'^';*}*!  .,\' 


^''^■>tf^'' 


Section  of  foetal  lung  at  5  months,  showing  development  of  bronchi ;  no  alveoli. 

Fig.  6. 


^'He^.. 


Section  of  infant's  lung  at  10  months,  showing  increasetl  proportionate  amount  of  parenchyma 
in  comparison  with  the  foetal  condition  ;  distended  alveoli. 


THE    INFANT    AT    TERM.  33 

like  dilatations,  which  are  the  rudimentary  air-spaces.  Between  these 
dilatations,  and  separating  them  from  each  other,  is  loose,  delicate  con- 
nective tissue,  which  makes  up  the  remaining  bulk  of  the  lun^,  so  that 
what  subsequently  becomes  the  alveoli  is  about  equal  in  extent  to  the 
previous  bronchial  development.  This  rudimentary  air-space  is  destined 
to  enlarge,  subdivide,  and  finally,  in  early  adult  life,  to  occupy  all  the 
available  room  among  the  bronchial  branches.  The  loose  connective 
tissue  becomes  finally  thin,  dense  bands  constituting  the  stroma.  This 
serves  to  distribute  the  vascular  net-work,  and  upon  this  are  laid  the 
close-fitting  epithelial  linings  of  the  air-spaces.  In  foetal  life  the  mucous 
membrane  lining  the  bronchial  tubes  is  loosely  attached  to  the  muscular 
walls,  and  is  commonly  seen  lying  in  wavy  folds  within  the  contractile 
ring,  where  the  same  delicate  connective  tissue  loosely  holds  the  growing 
tissues  together.  As  has  been  said,  the  aerating  portions  of  the  lungs 
develop  as  bud-like  dilatations  at  the  tips  of  the  smallest  bronchi.  These 
dilatations  in  the  course  of  their  development  extend  into  the  stroma. 
The  epithelium,  changing  from  the  columnar  type  characteristic  of  the 
smaller  bronchi,  covers  the  newly  made  walls  with  flat  respiratory  epi- 
thelium. At  birth  the  loose  connective-tissue  stroma  of  the  foetal  lung  of 
five  months  has  been  condensed  into  rather  thick  alveolar  walls.  Another 
feature  of  the  child's  lungs  as  contrasted  with  those  of  adults  is  the  be- 
havior of  the  blood-vessels.  Being  loosely  restrained  in  the  walls,  they 
easily  become  distended  and  tortuous  and  encroach  upon  the  cavity  of  the 
alveoli.  With  small  alveoli,  thick  walls,  and  abundant  distribution  of 
vessels,  it  is  easy  to  understand  how,  in  hypostasis,  distention  of  the  ves- 
sels may  be  an  important  factor  in  displacing  the  air  in  feeble  subjects 
with  weakened  respiratory  vigor  and  partially  obstructed  bronchi. 
Finally,  the  lung  of  the  infant  differs  from  that  of  the  adult  mainly  in 
the  following  respects.  Proportionately  the  extent  of  the  bronchial  tubes 
is  greater  than  that  of  the  air-spaces.  The  connective-tissue  stroma  is 
likewise  in  greater  abundance  and  tends  to  cellular  proliferation.  The 
submucous  connective-tissue  of  the  bronchi  is  loose  and  more  abundantly 
supplied  with  nuclei,  and  its  vessels  are  held  more  loosely.  The  cells 
lining  the  air-spaces  form  a  continuous  layer.  The  alveoli  are  small, 
their  epithelium  proliferates  abundantly,  and  the  absorbents  accomplish 
their  Avork  slowly,  the  blood-vessels  playing  a  more  important  role. 
These  facts  are  to  be  borne  in  mind  in  connection  Avith  the  bronchial 
lesion  which  forms  so  important  a  part  of  bronchopneumonia. 

ABDOMEN. — The  essential  differences  between  the  abdomen  of  the 
infant  and  that  of  the  adult  are  the  great  size  of  the  livei-  in  the  former, 
and  also  the  relatively  large  size  of  the  kidneys  and  the  suprai^enal  capsules. 

The  liver,  especially  on  the  right  side  of  the  abdomen,  encroaches  on 
the  space  which  is  later  occupied  by  other  organs.  Its  relative  weight  to 
that  of  the  whole  body  at  birth  is  about  1  to  18.     (McClellan.) 

On  the  left  side  of  the  abdomen  these  conditions  are  not  of  much 


34 


PEDIATRICS. 


Pig.  7. 


Lobulated   kidney,   natural  ,-iz 
three  days  old.      <S'  Ji  marki 
capsule.      Warreu   Museum 
versitv. 


iiiiporlaiice.  but  un  the  right,  occumug  a.s  they  do  in  eoniiectiou  with  the 
great  size  of  the  liver,  the  large  kidney  occupies  a  lower  position,  and 
thus  still  further  curtails  the  free  space  in  the  right  Hank.     Viewed  from 

the  stand-point  of  the  adult  condition  the 
relations  are,  as  has  been  pointed  out  by 
Henke,  much  more  peculiar  on  the  right 
^^SS  than  on  the  left.  The  kidney  as  a  whole 
is  lobulated,  as  seen  in  Fig.  7. 

Uric    Acid   Infarction. — At    birth    a 

prenatal    condition,    represented    by    an 

Infant  orange  or  a  light  red  colored  deposit  near 

s  the  suprarenal  the  pvramids  in  the  straight  tubules  of  the 

Q,  Hars-ard   Uni-  ^  '  " 

kidney,  exists  normally.     This  condition 

is  called  the  uric  add  infarction,  and  the 

deposit  consists  of  urate  of  ammonium,  amorphous  urates  mixed  Avith  uric 

acid  crystals,  and  some  epithelial  cells.    (Plate  III.,  3  and  5,  facing  page  77.) 

The  suprarenal  capsules  at  birth  quite  cover  and  surmount  the  kid- 
neys, as  seen  in  Fig.  7. 

Stomach. — The  stomach  at  birth  is  remarkably  small,  and  more  tubu- 
lar than  in  the  adult,  the  fundus  bemg  but  slightly  developed.  It  is  con- 
sequently even  more  vertical  than  in  the  adult,  for  it  is  the  enlargement 
of  the  greater  cid-de-sac  that  makes  the  obliquity  of  the  axis  pronounced. 

Fig.  8,  representing  a  stomach  taken  from  an  infant  three  hours  old, 
shows  very  well  the  organ  at  birth.  Its  capacity  Avas  25  c.c.  (f  ounce). 
The  weight  of  the  infant  was  2500  grammes  (5i  pounds).  Although  the 
weight  Avas  below  that 

of  the  average  infant  ^^^-  ^• 

at  birth,  the  stomach 
was  of  about  the  aver- 
age size,  as  was  shown 
by  its  gastric  capacity. 

Duodenum.  —  The 
duodenum,  in  the 
adult,  has  of  late  usu- 
ally been  described 
as  ring-shaped,  but 
it  generally  presents 
pretty  well  marked 
angles,  which  divide 
it  into  a  horizontal 
part  running  back- 
ward, a  descending 
one  along  the  right 
side  of  the  spine,  a  transverse  one  crossing  usually  the  third  lumbar 
vertebra,  and.  finally,  an  ascending  part  along  the  left  of  the  spinal  col- 


;tomach,  natural  size.    Infant  three  hours  old. 
Warren  Museum,  Harvard  University. 


THE    INFANT   AT    TERM.  35 

umii,  which  brings  the  end  to  about  the  same  level  as  the  beginning. 
Sometimes  the  last  two  parts  are  represented  by  a  single  one  running 
obliquely  upward  to  the  left,  in  which  case  the  duodenum  is  called  Y- 
shaped.  The  first  horizontal  portion  is  often  somewhat  dilated,  and  its 
walls  are  smooth,  the  folds  beginning  usually  with  the  descending  por- 
tion. The  walls  of  the  duodenum  just  beyond  the  pylorus  are  Hned  by 
a  continuous  layer  of  Brunner's  glands,  which  extends  through  the  first 
part,  becoming  more  or  less  broken  up  towards  the  end.  In  the  infant 
the  shape  of  the  duodenum,  as  shown  by  plaster  casts  (specimens  in 
Warren  Museum),  is  more  nearly  that  of  a  ring,  the  two  lower  angles 
being  rounded  off.  A  constriction  is  often  (perhaps  usually)  seen  at  the 
junction  of  the  first  and  second  parts,  but  Dwight's  casts  of  the  infant's 
duodenum  do  not  show  the  folds,  which  are  very  striking  in  the  casts 
taken  from  adults.  That  is  to  say,  those  of  the  infant  show  a  few  deep 
cuts  into  the  cast  instead  of  a  great  many  near  together.  We  have  seen  the 
folds,  however,  very  richly  developed  in  an  infant  of  three  weeks.  In 
one  case,  that  of  a  female  six  weeks  old,  Dwight  found  the  duodenum  of 
the  V-shaped  pattern,  and,  what  is  more  remarkable,  after  it  had  passed 
the  gall-bladder  it  was  surrounded  by  peritoneum  so  as  to  swing  freely  as 
a  loop  suspended  from  the  posterior  abdominal  wall.  As  to  Brunner's 
glands,  a  few  observations  on  young  children  have  suggested  that  they 
^vere  rather  less  developed  relatively  than  in  the  adult,  but  this  may  not 
always  be  the  case.  The  duodenum  has  been  compared  to  a  trap,  its 
ends  being  always  higher  than  its  middle,  Avhich  is  thus  fitted  to  retain 
the  fluid  poured  into  it  from  the  liver,  the  pancreas,  and  its  own  glands, 
besides  that  which  it  receives  from  the  stomach. 

The  number  and  size  of  the  folds  and  the  shape  of  the  duodenum  in 
the  adult  would  tend  to  delay  the  passage  of  its  contents  through  it,  and 
thus  it  also  prevents  the  passage  of  gases  from  the  small  intestine  upward 
into  the  stomach.  If  it  be  true  that  in  the  infant  the  system  of  folds 
is  less  developed,  its  passage  would  be  relatively  easy,  which  with  a  fluid 
diet  seems  desirable. 

Intestines. — From  what  we  know  of  the  development  of  the  intestinal 
tract,  which  was  at  first  merely  a  loop  loosely  attached  to  the  posterior 
abdominal  wall,  it  is  natural  to  expect  that  in  the  infant  and  young 
child  it  should  be  less  fixed  than  in  adult  life ;  and  this  is,  in  fact, 
the  case.  The  difference  is  most  striking  in  the  large  intestine,  and  is 
shown  particularly  in  the  caecum,  ascending  colon,  and  sigmoid  flexure. 
That  this  condition  gives  rise  to  dangers  is  evident,  and  we  should  say  that 
there  is  a  strong  probability  that  the  cases  of  infantile  intussusception 
which  occur  with  unusual  frequency  during  the  middle  of  the  first  year 
may  arise  from  this  anatomical  peculiarity,  and  this  makes  a  thorough 
knowledge  of  the  anatomy  of  the  intestine  important.  In  the  foetus  at 
fuU  term  the  length  of  the  intestine,  and  especially  of  the  colon,  is  singu- 
larlv  constant. 


36  PEDIATRICS. 

Small  Intestine. — The  average  measurement  of  the  small  intestine  in 
infancy  is  287  cm.  (9  feet  5  inches).  The  variation  may  amount  to  61 
cm.  (about  2  feet). 

Large  Intestine. — The  large  intestine  at  birth,  according  to  Treves, 
measures  56  cm.  (about  1  foot  10  inches).  So  regular  are  these  measure- 
ments that  the  greatest  variation  that  we  liave  met  with  in  the  colon  was  as 
Uttle  as  12.7  cm.  (about  5  inches). 

Sigmoid  Flexure. — But  little  of  the  sigmoid  flexure  is  found  in  tlie 
pelvis  at  birth. 

PELVIS. — The  small  size  of  the  infant's  pelvis  is  to  be  noted  also  as 
the  cause  which,  to  a  greater  or  less  extent,  forces  the  pelvic  organs  of 
later  life  into  the  abdomen  during  infancy. 

BLADDER. — In  the  infant  the  bladder  is  practically  wholly  an  ab- 
dominal organ. 

UTERUS. — At  birth,  part  of  the  uterus  is  above  the  brim  t)f  the 
pelvis. 

TEMPERATURE. — The  temperature  at  birth  is  slightly  higher  than 
a  few  days  later.     It  is  about  37.2°  C.  (99°  F.). 

PULSE. — The  pulse  varies  from  120  to  140  to  the  minute  at  birth, 
and  it  is  at  times  irregular,  especially  during  the  first  few  hours. 

RESPIRATION. — The  respiration  is  about  45  to  the  minute,  but  it  is 
of  a  very  irregular  type,  and  the  rhythm  changes  continually.  The 
breathing  is  superficial,  sometimes  quick,  and  again  dying  away  so  as  to 
be  almost  imperceptible.  This  condition,  if  occurring  in  an  older  child, 
would  be  a  symptom  of  grave  disease,  but  may  be  said  to  be  normal^  at 
birth.  The  rate  may  be  much  quicker  than  45,  and  we  have  frequently 
observed  it  as  high  as  60  or  70. 

Fig.  9. 


Quick  Pause  Slow  Quiok 

Respiration  at  birth  for  one-fourth  minute.    Awake,  but  quiet. 

HEIGHT. — ^The  new-born  infant's  average  height  is  in  the  male  about 
49.5  cm.  (19|  inches);  in  the  female  48.5  cm.  (19|  inches). 

WEIG-HT. — The  weight  of  the  male  infant  is  usually  rather  greater 
than  that  of  the  female.  The  average  Aveight  in  a  large  number  of  cases 
showed  that  of  the  male  to  be  3250  grammes  (7|  pounds),  Avhile  that  of 
the  female  is  3150  grammes  (7  pounds).  Parker,  in  a  careful  examination 
of  170  infants  at  birth,  of  whom  89  Avere  males  and  81  females,  found 
that  the  average  weight  of  the  males  was  3520  grammes  (7|  pounds), 
while  that  of  the  females  Avas  3290  grammes  (7i  pounds).  There  is, 
then,  a  certain  amount  of  latitude  to  be  accepted  in  this  question  of  Aveights. 


THE   INFANT   AT   TERM.  37 

The  A\eig-ht,  however,  has  so  close  a  connection  with  the  vitality  of  the 
infant,  that  although  we  often  see  infants  of  light  weight  vigorous  and 
thriving,  and  those  of  considerable  weight  failing  to  gain,  yet  as  a  general 
index  of  vitality  the  Aveight  is  a  valuable  starting-point  and  guide  for  our 
treatment.  Rules  and  averages  of  this  kind  are  not  to  be  depended  upon 
absolutely,  but  simply  represent  conditions  which  with  other  important 
factors  aid  in  solving  the  problem  of  vitality. 

VITALITY. — In  the  early  hours  and  days  of  existence  it  is  the  dis- 
turbance of  the  equilibrium  of  the  infant's  vitality  which  is  especially  to 
be  feared  and  combated  rather  than  the  specific  morbid  processes  of  later 
childhood.  We  should  therefore  in  each  infant  carefully  determine  the 
degree  of  inanition  which  we  are  called  upon  to  deal  with  at  this  period 
of  life,  and  we  have  personally  found  it  useful,  as  shown  in  the  following 
table,  to  divide  the  weak  and  strong  infants  into  groups  according  to  their 
weiglits,  allowing  a  somewhat  lighter  weight  for  girls  than  for  boys. 

TABLE   1. 

RelatixDi  of    Weight  io  Vitality. 

Groups.  "Weight.                                                                Vitality. 

1 2000  gniiiniies  (ahout  4k  pounds) Very  L>\v. 

2 2500^  "  "  o|  "  Low. 

3 3000  "  "  6^  ='  Fair. 

4 3500  "  "  7J  "  Normal. 

5 4000  "  "  8  "  High. 

6 4500  "  "  9  "  Very  high. 

HANDS. — At  birth  it  is  quite  remarkable  to  find  with  what  manifest 
strength  the  infant  can  grasp  your  finger.     The  nails  are  well  formed. 

FEET. — A  very  important  part  of  the  infant's  anatomy  is  the  foot. 
The  later  researches  of  Dane  have  shown  that  the  foot  of  the  new-born 
infant  is  not  normally  flat.  On  the  contrary,  the  bones  are  so  arranged  as 
to  form  an  arch  that  is  even  higher  in  proportion  to  its  length  than  that 
found  in  adult  feet.  The  flat  appearance  is  caused  by  the  presence  in  the 
sole  of  a  very  large  amount  of  fat  tissue  and  the  greater  proportionate 
size  of  the  adductor  pollicis  muscle. 

BONE  MARRO^W.— At  birth,  and  in  the  early  months  of  life,  the 
marrow  of  the  bones  is  red,  as  shown  in  Plate  II.,  facing  page  75. 

The  red  color  caused  by  the  numerous  injected  blood-vessels  is  more 
intense  at  the  central  portion  of  the  section  of  this  bone  than  at  the 
periphery  or  towards  the  ends. 

FUNCTIONS. — Voice. — -The  normal  infant  at  birth  should  present  a 
developed  voice,  and  should  cry  vigorously,  thus  assisting  the  lungs  to 
expand  and  the  new  circulatory  mechanism  to  be  well  started. 

Sight. — Although  the  eye  is  anatomically  dcA^eloped  aiid  is  sensitive  to 
light,  and  although  the  visual  perception  is  also  possibly  developed,  yet 
there  is  still  a  lack  of  power  to  interpret  the  images  perceived. 


38  PEDIATRICS. 

HEARLNti. — The  auditory  sensations  appear  to  bo  rather  dull  during  the 
first  few  days  of  life.  This  is  possibly  due  to  the  absence  of  air  from  the 
tympanum  and  a  tumid  condition  of  the  tympanic  mucous  membrane. 

Touch. — The  sense  of  touch  is  well  developed. 

Taste. — The  sense  of  taste  is  well  developed. 

Smell. — The  sense  of  smell  is  probably  well  developed;  bnf.  Ihis  is 
still  a  matter  of  dispute. 

Sebaceous  Glands. — The  I'unction  of  the  sebaceous  glands  is  fully  de- 
veloped at  birth. 

Lachrymal  Glands. — The  secretion  of  the  lachrymal  glands  is  not  de- 
veloped at  birth.  The  new-born  infant  does  not  shed  tears,  a  fact  of  some 
clinical  consecpience  in  connection  with  the  prognosis  as  to  the  convales- 
cence of  disease  in  the  early  days  of  life. 

Sweat  Glands. — The  function  of  the  sweat-glands  is  not  developed  at 
birth  as  a  rule,  but  according  to  our  observations  perspiration  in  certain 
individuals  certainly  occurs  at  a  much  earlier  period  than  is  usually  sup- 
posed. We  have  seen  an  infant,  premature  at  the  seventh  month,  perspire 
freely  one  week  after  it  was  born,  and  in  a  number  of  individuals  this 
function  must  exist  in  the  early  days  of  life. 

Salivary  Glands. — The  salivary  secretion  is  not  fully  estaJDlished  at 
birtli,  and  consequently  the  mucous  membrane  of  the  mouth  is  compara- 
tively dry.  The  peculiar  whitish  color  of  the  young  infant's  tongue  is  caused 
by  the  epithelium  not  being  washed  away  by  the  saliva  to  the  extent  that  it 
is  after  the  later  development  of  the  function  of  the  salivary  glands.  The 
amylohiic  function  of  the  saliva  is  very  slightly  present  at  birth.  The 
amylolytir  action  is  indeed  so  insignificant  that  it  merely  shows  us  that 
the  function  of  the  salivary  glands  in  the  early  months  of  existence  is  only 
partially  developed  and  certainly  should  not  be  called  into  use. 

Pancreas. — The  amylolytic  action  of  the  pancreatic  secretion  at  birth 
is  probably  not  all  developed.  The  fat  chgestion  is  fairly  developed  at 
birth.     The  proteid  digestion  is  fairly  developed,  but  not  fully. 

Bile. — According  to  Foster,  "■  the  excretory  functions  of  the  liver  are 
developed  early,  and  at  about  the  third  month  of  intra-uterine  life  bile- 
pigment  and  bile-salts  find  theh-  way  into  the  intestine.  A  quantity  of 
bile  secreted  during  intra-uterine  life  accumulates  in  the  intestine,  espe- 
cially in  the  rectum,  and  forms,  together  with  the  slighter  secretion  of 
the  rest  of  the  canal  and  some  desquamated  epithelium,  the  meconium. 
The  distmct  formation  of  bile  is  an  indication  that  the  products  of  foetal 
metaJDolism  are  no  longer  wholly  carried  off  by  the  maternal  circulation, 
and  that  to  the  excretory  function  of  the  liver  are  now  added  those  of 
the  skin  and  kidney." 

BLOOD. — It  is  impossible  by  the  methods  at  present  known  to  deter- 
mine exactly  the  total  amount  of  blood  in  either  infant  or  adult,  but,  while 
the  adult's  blood  is  approximately  about  one-thirteenth  of  the  entire 
weight  of  the  body,  the  infant's  is  represented  by  only  one-fifteenth.     A 


NORMAL   DEVELOPMENT.  39 

full  description  of  the  normal  blood  in  infancy  and  childhood  will  be 
found  on  page  874. 

LYMPHATIC  SYSTEM.— The  lymphatic  system  is  very  active  at 
birth. 

URINE. — The  amount  of  urine  secreted  during  the  first  two  days  of 
life  is  very  small,  and  its  specific  gravity  is  about  1010.  The  kidney 
shows  the  condition  of  the  uric  acid  infarction,  and  it  is  not  infrequent  to 
find  the  napkins  stained  with  a  uric  acid  deposit,  such  as  is  represented 
in  Plate  III.,  3  and  5,  facing  page  77. 

INTESTINAL  DISCHARGES.— Unless  a  discharge  of  the  contents 
of  the  intestine  has  taken  place  during  the  delivery,  as  is  so  often  seen  in 
breech  presentations,  it  occurs  immediately  or  very  soon  after  birth. 

Meconium. — The  discharge  which  first  comes  from  the  intestine  is 
called  the  meconium.  It  is  inodorous,  viscid,  slightly  acid,  and  of  a 
brownish-black  color,  such  as  is  represented  in  Plate  III.,  facing  page  77. 
The  meconium  contains  mucus,  epithelium  from  the  intestinal  mucous 
membrane,  epidermal  cells,  hairs,  and  fat-drops  from  the  vernix  caseosa 
Avhich  have  been  swallowed  with  the  amniotic  fluid  from  time  to  time, 
It  also,  according  to  Vierordt,  contains  the  constituents  of  the  bile,  and  its 
total  amount  is  from  sixty  to  ninety  grammes  (two  to  three  ounces),  of 
which  the  solid  part  forms  about  twenty  per  cent.  The  intestinal  con- 
tents at  birth  are  sterile. 

IV.    NORMAL  DEVELOPMENT. 

In  order  to  differentiate  normal  from  abnormal  conditions  in  the 
growing  infant  and  child,  the  different  stages  of  development  correspond- 
ing to  the  various  ages  should  be  studied. 

CORD. — By  a  process  of  disintegration  the  cord  at  about  the  seventh 
or  eighth  day  separates  from  the  living  tissues  around  the  umbilicus.  A 
certain  amount  of  bleeding  may  take  place  at  the  point  of  separation,  but 
this  is  usually  very  slight ;  it  may,  however,  be  the  beginning  of  one  of 
the  most  serious  forms  of  disease  in  the  new-born,  umbilical  hemorrhage. 
The  umbilical  depression  is  well  marked,  even  when  the  infant  cries,  and 
this  normal  anatomical  condition  following  the  separation  of  the  cord  can 
thus  be  distinguished  from  the  umbilical  prominence  representing  cases 
of  umbilical  hernia. 

SPINE. — The  time  of  consolidation  of  the  bodies  of  the  vertebrte  is 
not  accurately  known,  but  it  may  be  roughly  stated  to  begin  in  the  third 
year,  and,  probably,  to  end  in  the  seventh.  A  large  number  of  observa- 
tions must  still  be  made  before  the  various  stages  of  ossification  can  be 
determined.  The  statements  regarding  this  point  are  copied  from  one 
book  to  another,  and  are  often  cjuite  imaginary. 

The  union  of  these  chief  centres  to  form  the  bodies  of  the  vertebrae 
begins  in  the  lumbar  region,  and  is  first  completed  there.     This  union. 


40 


PEDIATRICS. 


however,  had  nut  taken  jdaee  in  Ihe  (k)rsal  and  cervieal  region  v\^  Ihe 
child  said  to  be  three  years  old,  used  for  •■  The  Frozen  Sections  of  a 
Child''  (Dwight).  On  the  other  hand,  in  a  girl  of  five  or  six  years,  figured 
by  Symington,  the  process  was  found  to  be  hardly  finished  in  the  lumbar 
region,  and  higher  up  it  seemed  about  the  same  as  in  the  younger  child. 
The  process  of  union  of  the  laniinte  is  probably  completed  in  the  first  few 
months  of  life. 

Length. — The  following  table  shows  the  results  of  the  measurements 
of  the  spines  of  children  by  various  authorities.  There  is  a  remarkalDle 
uniformity  of  observations  by  different  men  in  spite  of  the  errors  incident 
to  the  personal  ec{uation  of  the  investigators  and  the  individual  variation 
which  doubtless  exists.  The  relative  length  of  the  dorsal  (more  properly 
the  thoracic)  region  is  shown  to  be  somewhat  greater  than  that  of  the 
adult ;  still  it  appears  that  after  the  age  of  five  or  six  the  proportions 
are  not  far  from  those  of  after-life. 

TABLE  2. 

Length  of  Spine  to  Sacrum. 


Absolute  Length,  in  Millimetres 

Relative  Length. 

Total  =  100. 

Age. 

Observer. 

Cervical. 

Dorsal. 

Lumbar. 

Total. 
208 

Cervical. 

Dorsal. 

Lumbar. 

3  months  . . . 

Rasenel 

.50 

100 

58 

24 

48.1 

27.9 

6  months  .  .  . 

.    Aeby 

52.5 

103 

60 

215.5 

24.3 

47.5 

27.8 

6  months  . . . 

.    Aeby 

53.5 

107 

61 

221.5 

24.1 

48.6 

27.5 

10  months  . . . 

.    Dwischt 

61 

125 

1 1 

263 

23.2 

47.5 

29.2 

2  years,  hov . 

.    Easenel  .... 

70 

140 

90 

300 

23.3 

46.7 

30 

2  years,  hov . 

. ;  Aeby 

79.5 

153.5 

98 

331 

24 

46.4 

29.6 

3  years,  girl . 

.  1  Dwight 

78 

162 

101 

341 

22.9 

47.5 

29.6 

4  years,  girl. 

.  ■  Aeby 

79.9 

162 

103.3 

345.2 

23.1 

46.9 

29.9 

5  years,  boy . 

.    Symington  . 

80 

170 

104 

354 

22.5 

48 

29.4 

5  years,  boy . 

. ;  Easenel 

80 

180 

135 

395 

20.3 

45.6 

34.2 

6  years,  boy. 

.    Spnington  . 

80 

175 

106 

361 

22.2 

48.5 

29.3 

9  years,  girl. 

.    Easenel  .... 

85 

195 

150 

430 

19.8 

45.4 

34.9 

11  years,  boy. 

.    Aeby 

91 

218.7 

153.5 

463.2 

19.7 

47.2 

33.1 

13  3"ears,  girl. 

.    Symington  . 

95 

220 

136 

451 

21.5 

48.7 

29.1 

16  years,  girl. 

.  i  Aeby 

100 

221.9 

151 

472.8 

21.1 

46.9 

31.9 

16  years,  girl. 

.  \  Aeby 

107.5 

229.5 

152.5 

489.5 

21.9 

46.9 

31.1 

17  years,  girl. 

.    Dwight 

113 

250 

161 

524 

21.5 

1 

47  7 

30.7 

The  figures  to  the  left  of  the  douJDle  Une  in  the  table  express  the  abso- 
lute length  of  the  different  portions  of  the  spine,  in  millimetres. 

Those  to  the  right  are  the  same  figures  reduced  to  terms  of  100, 
nithin  a  fraction. 

Flexibility. — The  spine  is  very  flexible  at  birth.  This  flexibility  be- 
comes less  as  the  infant  grows  older. 

In  the  cadaver  of  a  female  child  of  ten  months  it  was  found  that  ex- 
tension was  no  longer  so  free  as  in  the  earlier  months,  and  it  required  a 
strong  pull  to  make  the  head  touch  the  nates.  The  dorsal  region,  how- 
ever, could  still  be  made  concave  behind.     Flexion  was  free,  especially  in 


NORMAL   DEVELOPMENT.  41 

the  lower  part  of  the  kunhar  region,  where  the  pelvis  and  legs  could  be 
swung  forward.  On  rotation  the  head  could  be  turned  through  an  arc  of 
90°  without  using  the  joint  between  the  atlas  and  the  axis.  In  a  male 
child  of  the  same  age,  extension  of  the  spine  was  found  to  be  still  more 
restricted. 

Curves. — At  birth  there  are  no  natural  curves  except  the  sacral  in 
the  infant's  spine.  An  important  factor  in  the  production  of  the  curves 
in  the  cervical  and  dorsal  regions  is  probably  the  pull  of  the  muscles. 
The  dorsal  curve  seems  to  be  a  permanent  condition  of  a  part  of  the 
general  curve  of  the  body.  As  soon  as  the  muscles  of  the  back  of  the 
neck  contract  so  as  to  raise  the  head  from  the  chest,  the  front  of  the 
neck  will  be  convex,  and  finally  this  becomes  the  habitual  position.  As 
Symington  has  pointed  out,  however,  this  cervical  curve  is  never,  prop- 
erly speaking,  consolidated,  for  it  can  always  be  obliterated  by  a  change 
of  the  position  of  the  head.  The  production  of  the  lumbar  curve  is 
more  complicated.  If  an  infant  be  laid  on  its  back  on  a  table,  the 
knees  are  raised  and  fall  apart ;  if  they  are  brought  together  and  for- 
cibly pressed  down,  the  lumbar  region  will  spring  up  from  the  table 
and  the  beginning  of  a  lumbar  curve  will  appear.  It  is  supposed  that 
this  is  caused  by  the  shortness  of  the  ilio-femoral  ligaments,  which,  when 
the  thighs  are  brought  down,  flex  the  pelvis,  throwing  the  promontory  of 
the  sacrum  forward.  As  the  child  begins  to  stand,  the  body  is  inclined 
forward,  and  Avhen  this  is  straightened  by  the  muscles  of  the  back  the 
same  thing  occurs,  for  of  course  it  is  unimportant  whether  the  legs  are 
extended  on  the  trunk  or  the  trunk  on  the  legs. 

This  curve,  therefore,  is  first  observed  when  the  child  is  one  or  two 
years  old,  but  it  is  not  until  some  time  later  that  it  is  habitually  present. 
It  can  be  obliterated  up  to  adult  life.  The  tonicity  of  the  muscles  has  a 
great  deal  to  do  with  retaining  the  curves  of  the  spine  and  with  limiting 
its  movements.  The  importance  of  the  muscles  in  distortions  is  very 
great.  The  spine  of  the  child  is  flexible  in  many  ways,  and  the  unruly 
pull  of  a  muscle  may  easily  produce  a  lasting  effect.  Not  only  should 
the  muscles  have  strength  enough  to  maintain  the  figure  without  conscious 
effort,  but  their  action  should  be  symmetrical  on  both  sides,  and  should 
also  have  a  proper  relative  force  before  and  behind.  The  importance  of 
light  gymnastic  exercises  is  now  generally  understood. 

Fig.  3,  page  23,  represents  the  curves  of  the  infant's  spine  at  birth 
and  also  at  different  ages  up  to  the  period  of  standing. 

Surface  Anatomy. — The  surface  anatomy  of  the  spine  is  of  much  im- 
portance in  the  child.  In  the  infant,  except  perhaps  in  the  neck,  the  back 
is  rounded ;  later  it  is  more  flattened,  and  the  line  of  the  spinous  pro- 
cesses is  rather  prominent.  When  we  examine  the  dissected  spine  from 
behind  we  find  it  very  different  from  that  of  the  adult.  In  the  infant  the 
laminae  look  more  directly  backward,  and  their  presence  in  the  median 
line  is  marked  by  knobs  and  ridges  very  different  from  the  spine  of  the 


42  PEDIATRICS. 

adult  Up  to  a  year,  or  perhaps  eighteen  months,  the  proportions  are 
not  very  different,  but  the  spine  at  three  years  shows  that  a  great  change 
has  occurred,  for  the  spinal  processes  now  stand  out  in  a  prominent  row, 
and  present  very  nearly  adult  })roportions.  The  greatest  ditterence  is  in 
the  dorsal  spines,  which  are  relatively  broader  at  their  points  and  less 
gracefully  drawn  out  than  in  the  adult.  The  bodies  of  the  vertebrfe  still 
remain  less  deep,  and  therefore  the  relative  positions  of  the  spines  and 
bodies  show  less  difference  than  might  be  expected.  At  six  or  seven 
years  the  spine  has  made  still  further  progress  towards  the  adult  propor- 
tions. By  the  end  of  the  second  year  the  back  of  the  living  child  is  not 
only  flatter  and  broader  (the  results  of  continuous  changes),  but  there  is 
the  appearance  of  the  median  furrow,  and  at  five  or  six  the  differences  in 
this  respect  from  the  adult  are  not  marked.  It  is  barely  possible  to  count 
the  spines  in  the  infant  and  young  child,  and  at  three  and  four  years  it  is 
not  very  easy,  though  less  difficult  than  in  the  adult. 

The  first  dorsal  spine,  and  not  the  seventh  cervical,  is  the  most  promi- 
nent in  that  region.  The  atlas  has  no  spine  at  all ;  the  spinous  process 
of  the  axis  is  thick  and  prominent,  perhaps  relatively  less  marked  in  the 
child  than  in  the  adult :  the  third  and  fourth  spines  are  very  small ;  the 
fifth  is  not  much  larger :  but  the  sixth  projects  more,  and  the  seventh  is 
said  to  be  usually  the  first  prominent  one.  The  relative  size  of  the  lower 
cervical  spines  varies  considerably.  The  sixth  may  be  the  first  to  assume 
prominence,  and  the  seventh  cervical  and  first  dorsal  may  exceed  it  but 
little.  It  is  easier  to  examine  a  child  of  three  years  and  upward  than  an 
adult,  on  account  of  the  greater  softness  of  the  tissues,  which  allows  us 
to  feel  more  deeply  in  through  the  furrow  of  the  neck,  and,  having  recog- 
nized the  axis  by  alternately  flexing  and  extending  the  head,  to  count  the 
cer^'ical  vertebrae  in  order.  If  it  should  be  in  any  case  absolutely  im- 
■■  possible  to  feel  the  third  and  the  fourth,  it  is  better  to  allow  a  certain 
space  for  them  and  to  call  the  next  one  the  fifth  than  to  assume  arbitra- 
rily that  a  certain  one  is  the  seventh.  Confirmatory  evidence  may  be 
gained  from  the  height  of  the  sternum. 

NECK.— (See  also  p.  24). 

Cricoid  Cartilage. — Symington  states  that  in  tvro  children  respec- 
tively five  and  six  years  old  the  lower  border  of  the  cricoid  cartilage  was 
found  to  be  at  the  lower  border  of  the  fifth  or  at  the  top  of  the  sixth  ver- 
tebra. The  posftion  of  the  head,  in  his  observations  at  intermediate  ages, 
in  these  measurements  varied  a  good  deal.  In  a  girl  of  thirteen  he  found 
that  it  had  reached  the  adult  posftion ;  that  is,  about  on  a  level  with  the 
top  of  the  seventh  vertebra. 

Epiglottis. — Symington  found  also  that  the  top  of  the  epiglottis  de- 
scends during  growth  from  about  the  level  of  the  lower  border  of  the 
atlas  to  the  middle  of  the  third  cervical  vertebra,  or  even  lower. 

Larynx. — This  high  posftion  of  the  larynx  would  imply  a  greater  part 
of  the  trachea  relatively  above  the  sternum,  but  this  is  neutralized  by  the 


NORMAL   DEVELOPMENT.  43 

high  position  of  the  latter.  The  amount  of  fat  in  the  neck  makes  the 
trachea  less  accessible.  The  greater  distance  of  the  trachea  from  the 
surface,  as  it  descends,  and  the  greater  danger  of  meeting  the  large  arteries 
and  veins  above  the  sternum  in  the  child,  are  points  of  anatomy  so  well 
known  in  connection  with  tracheotomy  that  it  seems  hardly  worth  while 
to  dwell  upon  them. 

Distance  from  CRicom  to  Sternum. — A  condensation  of  Tillaux's 
statements  of  the  distance  from  the  cricoid  to  the  sternum  is  given  in 
Table  3. 


TABLE  3. 

Belation  of  Cricoid  to  Sternum. 
Years.  Distance  from  Cricoid  to  Sternum. 

2\ 3.0  centimetres. 

3'.... 4  " 

3^ 4 

4  3.8  " 

4^ 4  " 

5" 4.5  " 

6 4.9  " 

6J 5.5  " 

7' 5.1  " 

7.i 4.5  " 


'f- 


5.25  " 

9   5.25  " 

9^ 6.5  '< 

10  6.5  " 

lOJ 6.5  " 

It  seems  rather  remarkable  that  at  ten  years  the  distance  should  be  as 
great  as  in  the  adult,  but  this  may  be  accounted  for  by  the  subsequent 
descent  of  the  larynx,  and  also,  probably,  by  its  proportionate  enlarge- 
ment (at  least  in  the  male)  about  puberty. 

The  peculiarities  of  the  relations  of  the  top  of  the  larynx  and  pharynx 
to  the  spine  in  the  young  child  are  points  of  much  practical  importance. 
Tlie  changes  Avhich  occur  during  growth  depend  largely  on  changes  in  the 
base  of  the  skull,  and  on  the  downward  growth  of  the  jaws,  which  will 
be  considered  presently. 

HEAD. CmCUMFERENCE     AND     CIRCUMFERENCE     RELATIVE    TO     ThORAX. — 

The  measurement  of  the  circumference  of  the  head  increases  very  rapidly, 
and  in  early  childhood  almost  attains  that  of  the  average  adult's  head. 

At  birth  the  average  circumference  of  the  head  is  about  33  cm.  (13 
inches),  and  the  thorax  1  or  2  cm.  (|-  or  |  inch)  less.  The  following 
table  shows  the  relative  and  proportional  growth  of  the  head  and  thorax 
up  to  the  period  of  puberty.  These  figures  represent  measurements  from 
somewliat  over  one  hundred  cases.  It  will  be  seen  that  the  circumference 
of  the  thorax  has  become  equal  to  that  of  the  head  by  the  end  of  the 
first  year ;  though  in  exceptional  cases  the  thorax  surpasses  the  head  at  a 


44  PEDIATRICS. 

luucli  earlier  period,  and  we  liave  even  seen  it  exceed  tlie  circumference  of 
the  head  at  birth.  Again,  in  some  cases,  the  head,  even  in  the  second 
year,  remains  larger  than  the  thorax.  After  the  second  year,  the  meas- 
urements of  the  head  vary  very  little,  and  depend  more  upon  the  individual 
than  upon  the  age  ;  the  thorax,  on  the  contrary,  increases  year  by  year. 
The  measurements  which  are  given  were  taken  almost  entirely  from 
boys.  Girls,  for  the  same  age,  show  a  proportionately  smaller  circum- 
ference for  the  thorax  and  also  for  the  head. 


TABLE  4. 
Oireumferences  of  Head  and  Thorax  from  Birth  to  Thirteen  Years. 
Age.  Read.  Thorax. 

Birth 33  cm.  (13  inches) 81  cm.  (12Unehes) 

5  weeks 38  cm.  (15  inches) 30  cm.  (14 J  inches) 

5  months 42  cm.  (16|  inches) 41  cm.  {\(i\  inches) 

9  months 45.5  cm.  (18  inches) 43  cm.  (17  inches). 

1  year. 45.5  cm.  (18  inches) 47.5  cm.  (18|  inches). 

2  years. 48  cm.  (19  inches) 51  cm.  (20J  inches) 

3  " 51  cm.  (20J  inches) 55  cm.  (21 1  inches) 

4  «'     .53  cm.  (21  inches) 54  cm.  (21|  inches) 

5  <<     .53  cm.  (21  inches) 54  cm.  (21f  inches) 

6  "     52  cm.  (20.^  inches) 55  cm.  ( 21|  inches) 

7  <'     54  cm.  (21}  inches). 54  cm.  (21}  inches) 

8  "     53  cm.  (21  inches) 59  era.  (23J  inches) 

9  "     54  cm.  (21}  inches) 61  cm.  (24  inches). 

10  "  53  cm.  (21  inches) 62  cm.  (24J  inches) 

11  "  56  cm.  (22J  inches) 63  cm.  (24|  inches) 

12  "  53.5  cm.  (21 J  inches) 63  cm.  (24|  inches) 

13  "  54  cm.  (21}  inches) 66  cm.  (26  inches). 

FoNTANELLES. — The  posterior  fontaneUe,  although  ordinarily  quite  per- 
ceptible at  birth,  soon  disappears,  either  from  overlapping  of  the  bone  or 
from  a  permanent  closure,  and  is  usually  imperceptible  by  the  sixth  week. 

The  anterior  fontanelle  seems  to  grow  larger  as  the  infant  grows  older,  up 
to  alDout  the  ninth  month  ;  this  point  is,  however,  disputed,  and  the  increase 
may  be  apparent,  rather  than  real.  It  also  seems  to  remain  stationary, 
or  almost  so,  from  the  ninth  to  the  twelfth  month,  and  then  decreases 
slowly.     It  should  be  closed  by  the  mneteenth  to  the  twentieth  month. 

Face  and  Cranium. — The  proportion  of  the  face  to  the  cranium  in 
infancy  is  as  1  to  8.  Froriep  has  also  made  observations  on  this  point 
in  older  children,  and  finds  the  following  proportions : 

TABLE  5. 

Proportions  of  Face  to  Cranium. 
Age.  •  Face.    Cranium 

Early  infancy 1  to  8 

2  yeai-s 1  to  6 

6  years 1 .  to  4 

10  years 1  to  3 

Adult  female 1  to  2i- 

Adult  male 1  to  2 


NORMAL  DEVELOPMENT. 


45 


The  small  size  of  the  facial  portion  of  the  skull  in  infancy  and  early 
childhood  is  shown  in  Fig.  11,  page  48,  of  the  infant  at  birth  and  at  three 
years,  and  also  in  Figs.  26  and  27,  facing  page  82,  of  the  infant  at  birth 
and  at  nineteen  months. 

Fig   10 


Infant  skull,  natural  size.    Anterior  fontanelle  4  X  3  i 
Warren  Museum,  Harvard  University. 


As  the  child  develops,  very  important  changes  occur  in  the  base  of 
the  skull,  one  of  the  greatest  of  which  is  the  downward  growth  of  the 
face.  Originally  the  base  of  the  skull  is  practically  flat.  The  sudden  rise 
of  the  basilar  process  in  front  of  the  foramen  magnum,  the  angle  formed 
with  it  by  the  body  of  the  sphenoid,  and  then  the  sharp  descent  of  the 
vomer,  are  adult  characteristics  of  which  at  birth  there  is  little  trace. 
The  nasal  cavity  is  shallow  and  relatively  long,  the  posterior  nares  are 
small,  and  the  vomer  approaches  the  horizontal.  The  nasopharynx  has, 
therefore,  very  little  height.    The  alveolar  processes  are  still  undeveloped, 


46  PEDIATRICS. 

and  the  ramus  of  the  lower  jaw  is  very  oblique,  so  that  the  cavity  of  the 
mouth  is  small.  As  a  consequence,  the  larynx  is  placed  very  high  up. 
One  of  the  chief  causes  of  its  descent  is  the  downward  growth  of  the  face. 

Brain. — Up  to  the  seventh  year  the  brain  sho^vs  an  active  growth, 
and  after  that  year  increases  slowly  in  weight.  'J'he  convolutions  arc  not 
fully  developed  at  birth,  and  are  gradually  perfected  as  the  child  grows 
older.  The  various  centres  of  the  brain  which  gradually  become  so 
highly  developed  in  later  childhood  have  but  little  action,  so  far  as  we  can 
judge,  at  birth  and  in  the  early  weeks. 

Dura  Mater. — An  important  anatomical  condition  in  connection  with 
the  brains  of  young  subjects  is  that  the  dura  mater  is  much  more  adhe- 
rent to  the  skull,  and  thus  presents  an  obstacle  to  the  collection  of  extrava- 
sations between  it  and  the  bone. 

Subarachnoid  Space. — The  subarachnoid  space  usually  contains  a 
larger  amount  of  fluid  in  childhood  than  in  later  life. 

Ear. — Thfi,-  roof  of  the  middle  ear  or  tegmen  tympani  is  formed  by  the 
tegmen  tympani  proper,  which  is  a  part  of  the  petrous  bone,  and  a  small 
part  of  the  squamous  bone.  At  birtli  one  finds  between  these  bones  a 
cleft  (petrosquamosal  fissure)  which  extends  backward  over  the  mastoid 
antrum.  Through  this  cleft  a  small  process  of  the  dura  extends  which 
contains  a  small  branch  of  the  middle  meningeal  artery  which  spreads  out 
over  tlie  upper  wall  of  the  middle  ear. 

Early  in  the  fifth  month  of  life  this  cleft  closes  and  so  later  in  life  it 
becomes  the  petrosquamosal  suture. 

The  importance  of  this  fissure,  which  is  filled  with  connecting  tissue,  in 
transmitting  pus  from  the  middle  ear  to  the  cranial  cavity  appears  to  be 
slight,  for  in  infants  in  whom  the  fissure  is  wide  open  we  find  otitic  intra- 
cranial suppurations  less  seldom  than  in  adults  in  whom  the  fissure  is 
closed.  Pus  in  the  middle  ear  and  antrum  can  pass  much  more  readily 
through  the  open  squamo-mastoid  fissure,  and  so  appear  under  the  skin 
covering  the  mastoid. 

In  the  new-born  there  is  already  a  well-formed  antrum  but  no  mastoid, 
only  a  little  protuberance  which  at  the  end  of  the  first  year  contains  a  few 
pneumatic  cells.  In  the  third  year  the  mastoid  can  be  compared  with  the 
adult  mastoid.     (Korner.) 

The  osseous  meatus  is  not  developed  until  about  the  fourth  year.  In 
introducing  the  aural  speculum  under  four  years  of  age,  the  ear  should  be 
drawn  backward  and  downward,  instead  of  upward  and  backward  as  in 
older  children  and  adults,  or  the  canal  will  be  bent  on  itself. 

Petrosquamosal  Suture. — The  time  at  which  the  petrosquamosal  suture 
closes  is  not  at  present  known. 

Nasopharynx. — According  to  Disse,  the  nasal  cavity  begins  to  increase 
in  height  directly  after  birth,  and  goes  on  pretty  rapidly  until  the  begin- 
ning of  dentition,  when  it  is  slow  until  the  second  year  is  completed. 
After  the  first  set  of  teeth  are  cut,  the  growth  is  rapid  until  the  end  of 


NORMAL    DEVELOPMENT.  47 

the  seventh  year.  The  increase  m  breadth  occurs  in  the  last-mentioned 
period,  which  also  is  the  time  in  which  the  growth  of  the  olfactory  por- 
tion is  most  marked.  Disse  states  that  the  posterior  opening  doubles  its 
size  in  six  months,  remains  stationary  until  the  end  of  the  second  year, 
and  then  increases  again.  The  follo\ving  measurements  were  made  by 
D^vight : 

TABLE  6. 

Breadth   between  Ptery- 
Age.  '  Height  of  Posterior  Xares.  goid  Processes  at  Hard 

Palate. 

About  birth 6  to  7  millimetres  0  millimetres 

From  12  to  16  months 13  "  l(j  " 

'•     12  to  18        ••  .....15  '-  16  " 

'=     14  to  20        '•  14  "  17  " 

"     18  months  to  3  years 15  "  21  " 

-     2  to  4  years 15  "  20  ' 

About  6  years 16  "  20  " 

7  or  8  years 20  • '  22  " 

About  11  years 18  "  22  " 

17  years,  female 22  "  20  " 

These  figures  show  that  the  height  does  not  gain  the  predominance 
until  adult  age.  At  the  end  of  the  seventh  month  the  nasal  cavity 
approaches  the  adult  shape,  though  it  seems  broad  in  proportion,  and  has 
not,  of  course,  attained  its  full  size.  Merkol  has  shown  that  in  later 
adolescence  the  gro^vth  of  the  respiratory  portion  takes  place  chiefly  in 
the  middle  meatus.  In  infancy  the  posterior  border  of  the  vomer  is  very 
oblique.  With  the  gTo\\'th  downward  of  the  jaw  this  obliquity  is  much 
diminished  at  the  age  of  seven  or  eight  years. 

The  change  in  the  shape  of  the  pharynx  in  the  first  two  or  three  years 
is  very  great,  and  the  pharynx  of  older  children  resembles  more  that  of 
the  adult  than  that  of  the  infant.  Indeed,  at  four  ^veeks  we  find  the  tip 
of  the  epiglottis  on  a  level  with  the  lower  part  of  the  odontoid  process. 

Eustachian  Tubes. — The  course  of  the  Eustachian  tube  and  the  posi- 
tion of  its  opening  undergo  changes  corresponding  to  the  development  of 
the  nasal  cavity.  At  birth  the  tube  is  horizontal,  or  nearly  so.  In  the 
adult  the  cartilaginous  portion  slants  downward.  Nevertheless,  the  open- 
ing of  the  tube  is  opposite  a  higher  part  of  the  nose  in  the  adult  than  in 
the  child.  In  the  foetus  the  opening  is  below  the  level  of  the  hard  palate, 
which  it  reaches  at  birth.  Up  to  the  ninth  month  after  birth,  according 
to  Disse,  there  is  but  little  change.  After  that  time,  however,  the  opening 
is  distinctly  higher  than  the  floor  of  the  nasal  cavities.  At  four  years, 
Kunkel  found  it  to  be  three  or  four  millimetres  higher.  In  the  adult  it  is 
opposite  the  end  of  the  inferior  turbinate  bone. 

Pharyngeal  TonsiL — The  pharyngeal  tonsil  increases  after  birtli.  and 
by  the  end  of  the  first  year  has  a  length  of  eighteen  millimetres. 

Hard  Palate. — In  a  child  of  three  years  or  less  the  line  of  the  hard 
palate  strikes  about  the  middle  of  the  basi-occipital  bone.  It  would 
hardly  be  possible,  without  passing  the  finger  round  the  soft  palate,  to 


48 


PEDIATRICS. 


Fig.  11. 


feel  much  hig-her  than  the  arcli  of  the  atlas.  The  base  of  the  odontoid 
process  would  be  under  the  mucous  membrane  seen  at  the  back  of  the 
throat  through  the  open  mouth.  The  tip  of  the  epiglottis  is  at  the  junc- 
tion of  the  odontoid  with  the  body  of  the  axis.  Only  the  very  top  of  the 
third  vertebra  could  be  satisfactorily  explored.  At  six  and  at  thirteen 
(Symington's  plates)  the  line  of  the  hard  palate  has  about  the  adult  direc- 
tion,— that  is.  it  strikes  alDout  the  top  of  the  atlas  or  the  basilar  process 
neai"  its  beginning.  In  both  the  finger  could  probably  examine  the  verte- 
hrse  from  the  first  to  the  fourth  inclusive.  The  atlas,  however,  would  be 
reached  with  much  more  difficulty  in  the  older  than  in  the  younger  sub- 
ject, as  the  relations  oft  he  soft  palate  are  more  nearly  those  of  the  adult. 

Mouth. — As  the  infant  grows  older  the  mouth  becomes  an  organ  more 
adapted  for  certain  uses  beyond  that  of  a  mere  means  of  entry  for  the 
food  to  the  stomach. 

Maxillary  Bones. — 
The  ossification  of  the 
maxillary  bones  begins 
early,  progresses  slowly, 
and,  together  with  the 
final  formation  of  the 
jaw,  is  completed  at  pu- 
berty. Fig.  11  repre- 
sents the  characteristic 
incomplete  development 
of  the  ramus  of  the  in- 
ferior maxillary  bone  in 
tlie  early  weeks  and 
months  of  life,  and  its 
almost  complete  devel- 
opment at  three  years. 

The  chief  character- 
istic, as  seen  in  Fig.  1 1 , 
is  the  oblique  angle 
which  the  ramus  makes 
with  the  body  of  the  bone 
at  birth,  and  this  becomes 
more  evident  when  com- 
pared with  the  jaw  at 
three  years.  The  much 
greater  proportion  of  the 

ramus  to  the  body  of  the  bone  at  three  years,  and  the  nearer  approach  to 
a  right  angle  where  they  join  are  noticeable. 

Teeth.— The  development  of  the  first  set  of  teeth  begins  at  about  the 
seventh  week  of  intra-uterine  life,  and,  progressing  slowly,  is  completed 
about  the  end  of  infancv.     At  birth  the  twenty  embryo  teeth,  ten  in  each 


Skulls  showing  development  of  ramus  at  birth  and  at  tliree  years. 
Warren  Museum,  Harvard  University. 


NORMAL    DEVELOPMENT. 


49 


jaw,  are  so  enclosed  in  the  alveolar  processes  that  nothing  but  the  smooth 
mucous  membrane  is  apparent  on  the  gums  above.  Below,  they  are  con- 
nected with  the  branches  of  the  inferior  dental  nerve  (an  important  clini- 
cal fact  to  be  remembered)  through  openings  at  the  bottom  of  the  alveolar 
processes.  When  calcification  of  the  neck  of  the  tooth  begins,  elongation 
also  takes  place,  and,  as  the  tooth  is  enclosed  in  bony  walls  below  and  on 
the  sides,  it  gradually  grows  through  the  point  of  least  resistance,  namely, 
the  gum,  which  covers  the  top  of  the  alveolar  processes.  The  continued 
pressure  gradually  causes  atrophy  of  the  mucous  membrane,  and  the  crown 
of  the  tooth  appears  on  the  edge  of  the  gums.  The  various  teeth  come 
through  the  gum  at  times  which  are  regulated  according  to  their  develop- 
ment, that  is,  at  times  corresponding  to  the  calcification  of  their  roots  and 
consequent  elongation.  This  process  usually  takes  place  in  groups  and 
with  considerable  regularity  in  the  average  normal  infant.  Variations, 
both  as  to  the  order  in  which  the  teeth  appear  and  in  the  time  of  their 
appearance,  are  so  common  that  it  seems  hardly  practicable  to  have  set 
rules  designating  these  times.  The  experience  of  different  physicians 
seems  to  differ,  but  all  practically  are  guided  by  very  general  rules.  An 
infant  may  be  born  with  one  or  more  teeth. 

The  first  tooth  may  appear  at  any  time  during  the  first  year  of  life,  or 
may  be  delayed  until  the  second  year  \vitliout  any  other  apparent  vice  of 
development.  In  like  iiianner.  every  kind  of  A^ariation  may  be  met  with 
in  the  order  in  A\hicli  the  teeth  appear,  ^vithout  the  slightest  evidence  of 
any  pathological  condition,  mental  or  otherwise,  being  found  either  at  the 
time  or  later.  It  is  therefore  unnecessary  to  alarm  the  parents  by  stating 
that  their  child  is  abnormal  because  it  has  not  cut  a  tooth  in  the  first 
year.  We  should,  however,  carefully  watch  these  children  and  be  sure 
that  their  food  contains  the  proper  nutritive  elements  not  only  for  their 
age,  but  also  for  their  individual  digestion. 

Fig.  12. 


Five  periods  of  development  in  the  first  deiititirin. 
4 


50  PEDIATRICS. 

The  appearance  of  the  teeth  in  groups  suggests  certain  practical  divis- 
ions to  determine  various  questions,  such  as  the  best  time  for  weaning,  or 
for  vaccination.  The  divisions  constitute  the  dental  and  interdental  periods. 
In  our  individual  experience,  the  first  tooth  appears  at  about  the  sixth  or 
seventh  month,  though  at  times  we  fmd  it  much  earlier,  as  at  the  fourth 
month,  and  later,  as  at  the  ninth,  tenth,  eleventh,  or  twelfth  month.  The 
first  tooth  which  develops  sufficiently  to  come  through  the  gum  is  in  most 
cases  one  of  the  middle  lower  incisors.  The  groups  and  the  dental 
periods,  allowing  always  for  many  variations,  are  as  follows : 

TABLE  7. 

Temporary  Teeth.     First  Dentition.     Twenty  in  Number. 

Dental  Periods.  Groups  of  Teeth. 

I.       6  to    8  months . , ,,.....    2  middle  lower  incisors. 

II.       8  to  10  months 4  upper  incisors. 

III.  12  to  14  months. 2  lateral  lower  incisors  and 

4  first  molars. 

IV.  18  to  20  months 4  canines. 

V-     28  to  32  months 4  second  molars. 

20 

The  second  set  of  teeth  begins  to  replace  the  first  at  about  the  sixth 
year. 

TABLE  8. 

Permanent  Teeth.     Second  Dentition.     Thirty-two  in  Number. 

Years.  Groups. 

6 .    .  4  first  molars. 

7 , , . , .  4  middle  incisors. 

8. .  .-. ....  4  lateral  incisors. 

9 4  first  bicuspids. 

10 ,....,.    ...  4  second  bicuspids. 

11 , 0 4  canines. 

12. o . « :.  ^ , 4  second  molars. 

17  to  2-5 , .  4  third  molars  ( wisdom-teeth). 

-32 

The  first  four  teeth  of  the  second  dentition  are  usually  called  the 
sixth-year  molars.  They  do  not  replace  any  of  the  temporary  teeth,  but, 
the  jaw  having  grown  so  as  to  provide  space  back  of  the  temporary  teeth, 
they  appear  back  of  and  next  to  the  second  molars.  This  usually  occurs 
at  about  the  sixth  year. 

In  the  seventh  and  eighth  years  the  permanent  incisors  replace  those 
of  the  temporary  set.  In  the  ninth  and  tenth  years  the  bicuspids  replace 
the  temporary  molars.  In  the  eleventh  year  the  permanent  canines  re- 
place the  temporary,  and  in  the  twelfth  year  the  four  second  molars 
appear.  This  really  completes  the  second  dentition  of  childhood,  twenty- 
eight  teeth.  The  remaining  four  molars  belong  to  a  period  of  adult 
growth.  Fig.  13  (page  51)  shows  the  manner  in  which  the  permanent 
teeth  replace  the  temporary  set  between  the  ages  of  six  and  twentv-five 
years. 


NORMAL    DEVELOPMENT. 


51 


THORAX. — Top  of  Sternum. — From  the  few  observations  which 
have  been  made,  the  top  of  the  sternum  m  infancy  and  early  childhood 
seems  to  be  opposite  some  part  of  the  first  or  second  dorsal  vertebra. 
(Dwight.) 

Diameters. — The  anteroposterior  diameter  of  the  interior  of  the 
thorax  is  to  the  transverse  diameter  at  three  years,  accordmg  to  Dwight's 
"Frozen  Sections,"'  as  one  to  two,  and  in  a  child  of  from  five  to  six 
(Syming-ton)  the  depth  is  even  relatively  greater.  The  ribs  bend  nmch 
less  backward  than  in  the  adult,  and  the  back  first  becomes  rounder  and 
then  flatter.  At  four  or  five  years  great  progress  in  gro^^ih  has  been 
made,  and  the  infantile  form  of  the  thorax  has  AvhoUy  disappeared. 
Slight  changes,  however,  probably  go  on  for  some  years. 

Ossification. — Towards  the  end  of  the  first  year  the  bone-centres  of 

Fig.  13. 


6  years.  j 

'  Trrl>y 


Eight  periods  of  development  in  the  second  dentition. 

the  sternum  have  grown,  and  the  sternum  has  gained  a  good  deal  in  sta- 
bility.    New  points  of  ossification  have  probably  appeared,  but  still  the 


54  rEDT.vnncs. 

The  theoretical  results  of  enlargement  of  the  thymus  are  very  serious. 
Resting  on  the  anterior  and  weaker  ventricle,  whicli  is  }^rolonged  upward 
into  th(!  pulmonary  artery,  it  may  interfere  with  the  pulmonary  supply  of 
blood,  and  by  compressing  the  innominate  veins  and  the  superior  cava  it 
may  interrupt  the  return  of  venous  blood  to  the  lungs.  Whether  or  not 
it  may  compress  IIk^  thoracic  duel  is  doubtful,  but  it  certainly  may  jjress 
on  the  trach(^a. 

The  thynuis  is  said  often  to  persist  for  seA'eral  years  alter  puberty,  but 
observations  are  not  immerous  on  this  point.  It  seems  to  disappear  from 
the  neck  and  from  the  front  of  the  heart  and  to  remain  longest  behind  the 
first  piece  of  the  sternum. 

Heart. — The  changes  which  take  place  in  the  infant's  heart  after  birth 
are  not  simultaneous,  which  is  a  point  to  be  remembered  in  making  a 
differential  diagnosis  of  cardiac  disease  diu'ing  the  iirst  ten  days  of  infancy. 
The  following  table  states  the  time  at  A\hich  these  changes  should  occur: 


TABLE  9. 

POST-NATAL    CHANGES    OF    FCETAL    CONDITIONS. 

Ductus  Venosus. — The  ductus  venosus  becomes  a  fibrous  cord  in  the  fissure  of  the 
ductus  venosus  in  from  two  to  five  days. 

Eustachian  Valve. — The  intra-uterine  function  of  the  Eustachian  valve  practically 
disappears  at  once  at  hirtli,  but  its  remains  can  be  found  for  an  indefinite  period.  (See 
heai't  dissected  by  Dr.  F.  Dexter,  Fig.  16,  facing  page  54. ) 

Foramen  Ovale. — The  foramen  ovale  usuallj'  closes  about  the  tenth  day,  but  the  upper 
part  sometimes  never  closes.  The  closed  foramen  ovale  is  seen  in  this  same  heart. 
(Fig.  16,  facing  page  54.) 

Ductus  Arteriosus. — The  ductus  arteriosus  is  about  1.5  cm.  (|  inch)  long,  has  a  diameter 
of  about  .25  cm.  (J  inch),  and  is  usually,  so  far  as  being  pervious  to  the  blood  is  con- 
cerned, obliterated  in  from  four  to  ten  days.  Its  remains  forms  a  fibrous  cord  connect- 
ing the  pulmonary  artery  and  the  aorta.      (See  Fig.  17,  facing  page  54.) 

Umbilical  Vein. — The  umbilical  vein  becomes  the  round  ligament  of  the  liver,,and  is 
obliterated  in  from  two  to  five  days.  As  pointed  out  by  Jacobi,  it  differs  from  the 
arteries  very  much  less  than  is  usual  with  the  veins  and  arteries  in  other  parts  of  the 
body.     Its  muscular  layer  is  very  large  and  strong. 

Umbilical  Arteries. — The  umbilical  arteries  in  their  upper  parts  become  obliterated  in 
fi-om  two  to  five  days,  forming  the  anterior  true  ligaments  of  the  bladder,  while  the 
lower  parts  remain  pervious  and  form  the  superior  vesical  arteries.  The  umbilical  arteries 
are  usually  thick  and  strong,  owing  to  the  great  development  of  their  muscular  layer. 

It  is  generally  lield  that  in  the  first  year  of  life  the  long  axis  of  the 
heart  is  more  nearly  horizontal  than  later.  The  apex  is  thought  by  many 
to  be  higher.  This  is  true  in  the  first  few  years,  but  somewhat  later  it 
may  be  found  in  the  adult  position,  or,  in  cases  where  the  lower  part  of 
the  sternum  is  backward  in  development  and  the  cartilages  crowded 
together,  it  may  be  in  a  lower  space  than  normal.  It  is  not  unlikely  that 
a  subsequent  change  in  these  portions  of  the  walls  would  correct  this. 
Thus,  if  in  the  early  condition  the  apex  were  at  the  sixth  intercostal 
space,  a  lengthening  out  of  the  lower  end  of  the  sternum  might  cause 
such  a  descent  of  the  ribs  as  would  bring  it  into  the  fifth  space. 


4.. 


j^^ 


y  rt 


to 


stomach,  spleen,  and  pancreas  at  10  months.    Natural  size,  posterior  view.    S  marks  the  spleen ;  P  marks 
the  pancreas  ;  D,  the  duodenum.    Warren  Museum,  Harvard  University. 


NORMAL  DEVELOPMENT.  55 

Weight. — As  shown  by  Boyd,  the  weight  of  the  heart  in  proportion 
to  that  of  the  whole  body  does  not  vary  much  at  different  ages,  so  that 
the  relative  labor  of  the  heart  does  not  materially  differ  between  the 
young  subject  and  the  adult.  In  the  first  few  years,  however,  the  increase 
of  the  weight  of  the  heart  is  greater  than  at  about  the  fourth  or  fifth  year, 
and  this  increase  is  again  greater  at  about  puberty.  These  are  facts  of 
practical  importance  to  be  remembered  when  we  are  studying  the  dis- 
eased conditions  of  the  heart. 

TABLE  10. 

Weights  of  the  Heart  during  its  Development.      (Boyd.) 
Age.  Grammes. 

At  birth 20.6 

1  ^  years 44. 5 

3  years 60.2 

6^  years 72.8 

lOJ  years 122.6 

17  years 233. 7 

Figs.  16  and  17  show  the  heart  in  the  early  days  of  life.     (Dexter.) 

Blood-Vessels. — "  According  to  a  number  of  actual  observations  made 
by  R.  Thoma,  the  post-foetal  growth  is  relatively  smallest  in  the  common 
carotid,  and  largest  in  the  renal  and  femoral  arteries.  Between  these  two 
extremes  there  are  found  the  subclavian,  aorta,  and  pulmonary  arteries. 
These  are  differences  which  correspond  with  the  differences  in  the  growth 
of  the  several  parts  of  the  body  supplied  by  those  blood-vessels.  In 
regard  to  the  renal  artery  and  the  kidney,  it  has  been  found  that  the 
transverse  section  of  the  former  grows  more  rapidly  than  the  volume  and 
weight  of  the  latter.  Thus,  it  ought  to  be  expected  that  congestive  and 
inflammatory  processes  in  the  renal  tissue  were  almost  predestined  by 
this  disproportion  between  the  size  of  the  artery  and  the  condition  of  the 
tissue.  Moreover,  the  resistance  to  the  arterial  current  offered  by  the 
kidney-substance  depends  also  upon  the  readiness  with  which  the  current 
is  permitted  to  pass  the  capillaries.  It  has  been  found  experimentally 
that  within  a  given  time  more  water  proportionately  can  be  squeezed 
through  them  in  the  adult  than  in  the  child.  These  anatomical  differences 
may  therefore  be  the  reason  why  renal  diseases  are  so  much  more  fre- 
quent in  infancy  and  childhood  from  all  causes,  with  the  exception  of  that 
one  which  is  reserved  for  the  last  decades  of  natural  life,  atheromatous 
degeneration."     (Jacobi.) 

Pulmonary  Artery. — It  is  doubtful  whether  there  is  any  essential 
difference  at  different  ages  in  the  origin  of  the  pulmonary  artery.  If  we 
say  that  in  the  infant  it  is  rather  higher  than  later,  we  have  stated  about 
all  that  is  justifiable. 

Lungs. — At  what  age  the  lungs  reach  their  full  expansion  forward  has 
not  been  determined.  It  would  appear  that  it  is  not  before  five  or  six 
years,  and  it  is  probably  still  later.  As  the  chest  expands  laterally  the 
lungs  of  course  increase,  and  the  relatively  greater  size  of  the  heart  to 


oO  PKDIATUICS. 

tlie  luu^'  ill  lh(>  iiifiiiil  depends  cssciiliall)  on  llic  size  of  llic  lungs.  Dtii'ing 
the  iirst  year  of  life  (according  In  Northrii)))  llic  alvcoljif  walls  are  iliick 
and  their  blood-vessels  are  held  loosely,  tt  is  iiol  milil  llic  fourth  or 
fifth  year  that  the  proportionate  achdt  <leveloj)nient  between  the  alveoli 
and  the  bronclii  is  attained,  and  the  stroma  lias  become  dense  and  bind- 
ing, restraimng  the  capillaries  as  in  adult  life.  In  inlaiit  life  the  underlying 
loose  tissue  lining  the  bronchial  tubes  gradually  biiuls  the  mucous  mem- 
brane to  the  fibromuscular  wall.  From  tliis  time  it  keeps  pace  in  its 
growtli  Avith  the  other  compact  tissues,  until  in  adult  life  it  appears  as 
dense  fibrous  bands.  During  the  first  two  years  the  air-cells  have  not 
attained  the  ]jroportionate  capacity  wliich  exists  in  adult  life,  and  the 
bronchial  tree  is  still  large  iii  proportion  to  tlie  dilating  and  multiplying 
alveoli.  Again  the  air-spaces  developed  from  the  terminal  bronchi  have 
covered  themselves  with  a  continuous  layer  of  flat  nucleated  epithelium. 
In  its  subsequent  growth  in  adult  life  it  is  believed  that  the  expanding 
alveolus  does  not  increase  its  number  of  epithelial  cells  to  cover  the  more 
extended  wall,  but  somewhat  enlarges  their  size,  and,  still  further,  that 
some  of  the  flattened  epithelium  loses  its  nuclei  and  expands  to  form 
large,  very  thin  plates,  called  respiratory  epithelium. 

ABDOMEN. — Liver. — The  liver  is  proportionately  large  at  birth  and 
in  early  childhood,  and  can  be  felt  below  the  edge  of  the  rD3s  hi  the  right 
hypochondrium,  its  border  being  about  1  or  2  cm.  (f  to  |  inch)  below  the 
costal  border  in  the  maminillary  line. 

Gail-Bladder. — The  fundus  of  the  gall-bladder  is  in  relation  to  the 
surface  of  the  body  about  that  of  the  ninth  costal  cartilage  near  the 
border  of  the  right  rectus  muscle.     (McClellan.) 

Spleen. — There  is  nothing  especially  to  be  noted  in  the  spleen  in  child- 
hood, as  it  corresponds  in  its  position  to  that  of  the  adult.  According  to 
Foster,  the  spleen  grows  rapidly  in  early  infancy,  but  in  proportion  to 
that  of  the  adult  is  both  absolutely  and  relatively  smaller.  It  is  said  that 
the  spleen  when  enlarged  encroaches  more  upon  the  thoracic  cavity  than 
in  the  adult,  owing  to  the  greater  resistance  offered  by  the  costocolic  fold 
of  the  peritoneum  upon  which  it  rests.  In  many  cases  of  enlarged  spleen 
from  varied  causes  Avhich  I  have  met  in  infants  it  has  seemed  to  me  that 
the  abdomen  was  encroached  upon  to  a  greater  extent  than  in  adults, 
and  that  both  the  physical  and  the  rational  signs  of  the  enlarged  splee 
in  the  thorax  were  relatively  insignificant  and  often  difficult  to  detect.' 

Pancreas. — The  function  and  the  anatomy  of  the  pancreas  correspond 
very  closely  to  that  of  the  salivary  glands.  It  is  situated  in  front  of  the 
first  lumbar  vertebra,  behind  the  stomach,  and,  according  to  the  variations 
produced  by  age  and  the  growth  of  other  parts,  lies  somewhere  between 
the  umbilicus  and  the  ensiform  cartilage. 

The  relative  position  of  the  spleen  and  pancreas  to  the  stomacli  and 
duodenum  is  shown  in  Fig.  18.  The  organs  were  obtained  at  the  autopsy 
of  an  infant  ten  months  old.     The  spleen  is  behind  the  cardiac  end  of 


nor:\[al  develop:\[ext.  57 

the  stomach,  and  very  near  its  extremity.  The  pancreas  extends  from 
"  the  spleen  (its  tail  being  in  close  apposition  to  the  latter  organ)  along  the 
posterior  surface  of  the  stomach  and  somewhat  upAvard  to  the  smaller 
curvature,  passing  behind  the  duodenum  and  its  head  resting  in  the  con- 
cavity of  the  duodenum.  The  curve  of  the  duodenum  is  also  clearly 
shown  in  the  specimen. 

Kidneys. — The  kidneys  are  lobulated  at  birth.  This  condition  con- 
tinues for  a  long  time  and  then  disappears,  the  lobulation  being  repre- 
sented by  the  pyramids  of  Malpighi.  A  few  years  after  birth  the  position 
and  relations  of  the  kidney  approximate  those  of  the  adult  (McClellan). 

Suprarenal  Capsules. — The  suprarenal  capsules  are  relatively  lai^e 
in  size,  and  gradually  approach  the  adult  proportions  as  the  child  grows 
older. 

Bladder. — Although  small  at  birth,  the  bladder  soon  becomes  capable 
of  great  distention. 

Symington,  from  a  frozen  section  which  he  made  in  the  median  plane 
through  the  body  of  a  child  seven  months  old,  shows  the  position  of  the 
bladder,  which  happened  to  be  distended.  It  takes  up,  practically,  the 
whole  of  the  lower  portion  of  the  abdo.men,  an  observation  Avhich  at 
once  suggests  the  difficulty  of  making  a  correct  physical  examination  of 
the  infantile  abdomen  during  life,  unless  certain  that  the  bladder  is  empty. 

The  above  fact  was  strikingly  exemplified  in  a  little  girl,  three  years  old,  who 
was  in  my  wards  at  the  Children's  Hospital.  She  was  sent  to  the  hospital  for  an  ex- 
amination in  reference  to  the  advisahility  of  an  operation  to  remove  an  abdominal 
tumor.  On  inspection,  a  rounded  prominence  extending  from  the  pubes  to  3  cm. 
(1^  inches)  above  the  umbilicus  could  be  plainly  seen.  By  palpation  the  tumor  could 
be  felt  extending  from  the  right  inguinal  region  over  to  the  crest  of  the  left  ilium. 
The  tumor  was  soft,  elastic,  and  fluctuating.  It  was  evidently  not  in  the  abdominal 
walls,  but  intra-abdominal.  The  child  was  said  to  have  been  ailing  for  over  a  week, 
and  to  have  grown  thin.  She  passed  her  urine  frequently,  but  in  small  quantities. 
Nothing  abnormal  was  found  on  an  analysis  of  the  urine. 

Suspecting  a  distended  bladder,  a  catheter  was  introduced,  and  270  c.c.  (9  ounces) 
of  urine  were  withdrawn.  The  tumor  immediately  disappeared,  and  the  abdomen 
became  soft  and  resonant. 

A  practical  lesson  to  be  drawn  from  this  case  is,  that  the  bladder 
should  invariably  be  carefully  examined  and  emptied  before  diagnostica- 
ting or  operating  in  abdominal  disease.  We  have  seen  a  distinguished 
laparotomist  neglect  this  precaution  in  a  young  child  while  operating  for 
appendicitis,  and  on  opening  the  abdominal  cavity  cut  directly  through 
the  walls  of  the  bladder.  The  urine  flowing  out  through  the  wound  was 
the  first  indication  to  him  that  he  had  failed  to  appreciate  that  in  early 
life  the  bladder  is  essentially  an  abdominal  organ. 

Stomach. — Many  peculiarities  of  the  digestive  tract  may  arise  from 
such  causes  as  the  different  proportionate  stages  of  development  of  the 
parts  of  the  gastro-enteric  tract  at  different  ages,  and  to  differences  in 


58  PEDIATRICS. 

their  peritoneal  attachments.  The  stomach  grows  very  rapidly,  and  pecu- 
liarities of  shape  appear  at  an  early  age.  AVe  have  seen  a  stomach  of  four 
and  one-half  months  which,  although  small,  was  relatively  broader  than 
in  the  adult.  The  adult  shape,  however,  is  soon  acquired.  How  perma- 
nent this  may  be  is  as  yet  unsettled.  There  is  no  doubt  that  great  dila- 
tation may  be  induced,  and  it  is  highly  probable  that  where  too  small 
quantities  of  food  are  given  the  normal  stomach  will  contract.  It  is  also 
very  likely  that  certain  shapes  are  acquired  at  a  very  early  period. 
D^^ight  has  shown  me  in  a  young  cliild  a  well-marked  antrum  pylori. — 
that  is.  a  pouch  above  the  pylorus,  which,  in  extreme  cases,  forms  almost 
a  separate  chamber.  It  is  evident  that  the  clinical  significance  of  our 
anatomical  knowledge  of  tiie  growth  of  the  stomach  in  the  first  year  is 
very  great.  This  question  of  gro^^ih  is,  in  fact,  one  of  the  most  unportant 
factors  m  the  problem  of  the  substitute  feeding  of  infants,  and  a  lack  of 
its  thorough  comprehension  often  leads  to  most  unfortunate  results. 

Capacity. — There  has  been  much  dispute  as  to  the  proper  method  of 
determming  the  gastric  capacity  during  infancy.  All  methods  are  open  to 
criticism,  but  by  combining  all  the  methods  and  makmg  general  deduc- 
tions we  can  arrive  at  practical  conclusions  concerning  the  size  of  the 
stomach  at  different  ages.  One  of  the  methods  which  may  be  employed 
is  a  clinical  one.  and  is  as  follows : 

A  mother  is  selected  who  is  youug,  healthy,  has  plenty  of  good  milk,  and  who 
has  a  healthy  infant  of  normal  size  and  weight,  and  appetite  according  to  its  age,  and 
one  that  is  thriving, — that  is,  digesting  well  and  gaining  regularly  about  30  grammes 
(1  ounce)  a  day.  The  infant  is  first  carefully  weighed  ;  next  it  is  allowed  to  nurse 
until  it  is  evidently  satisfied, — that  is,  practically,  until  it  feels  that  its  stomach  is  full. 
The  infant  is  then  weighed  again,  and  the  increase  in  weight  denotes  the  gastric 
capacity  in  ounces  of  milk.  Careful  investigation  has  shown  that  one  fluid  ounce 
of  milk  weighs  A^ery  nearly  30  grammes.  Certain  control  experiments  have  shown 
that  this  method  of  determining  the  gastric  capacity  is  a  practical  one.  It  is  well 
known  among  those  who  deal  in  cattle  that  when  fat  cattle  are  transported  long  dis- 
tances, as  from  Chicago  to  New  York,  they  are  found  to  have  lost  materially  in  weight, 
perhaps  thirty  or  forty  pounds.  If  these  cattle  are  allowed  to  fill  their  stomachs  with 
water,  an  increase  in  their  weight  will  be  found  corresponding  exactly  to  the  Aveight 
of  the  water  which  they  have  drunk. 

If  a  number  of  healthy  infants  of  different  ages  and  of  average  we^hts 
are  fed  and  weighed  in  this  way,  we  can  approximately,  by  comparing  the 
Rains  in  weight  which  correspond  to  the  same  ages,  determine  the  gastric 
capacity  for  each  age.  We  should  not.  however,  consider  this  by  itself  a 
reliable  method  for  determining  the  gastric  capacity,  as  it  is  open  to  many 
objections,  which  need  not  be  discussed  at  present.  One  source  of  error, 
for  instance,  is  the  variation  of  the  infant's  appetite,  which  may  cause 
either  too  great  distention  or  underfilling  of  its  stomach.  Another  method 
is  the  actual  measurement  of  the  gastric  capacity  at  the  autopsy,  with 
suitable  precautions  to  avoid  over-distention.     In  this  way  it  has  been 


NORMAL   DEVELOPMENT.  59 

determined  that  the  stomach  grows  very  rapidly  in  the  first  three  months 
after  birth,  grows  slowly  in  the  fourth  month,  and  is  then  almost  quiescent 
for  about  two  months.  It  then  begins  to  grow  again  until  it  has  reached  its 
adult  size.  Frolowsky's  rules  for  determining  the  gastric  capacity  of  young 
infants  approximate  in  their  results  so  closely  our  own  investigations  that 
we  have  prepared  from  them  figures  of  infants'  stomachs  at  different  ages 
and  at  different  periods  of  growth.  The  tracings  of  the  stomachs  are 
life-size.  Frolowsky  shows  that  the  activity  of  the  stomach's  growth  is 
very  great  in  the  first  quarter  of  the  first  year,  that  it  is  very  slight  in  the 
second  quarter,  and  that  it  again  shows  a  moderate  activity  in  the  last 
part  of  the  year.  He  represents  this  activity  of  the  stomach's  growth  by 
the  ratio  of  1  for  the  first  week  to  2J  for  the  fourth  week  and  3|  for  the 
eighth  week,  while  it  is  only  3|-  for  the  twelfth  week,  Sj-  for  the  sixteenth 
week,  and  3f  for  the  twentieth  week. 

The  gastric  capacity,  according  to  Fleischmann,  is  greater  at  the  same 
age  in  the  artificially  fed  than  in  the  breast-fed  infant.  This  observation, 
however,  in  all  probability  only  emphasizes  the  importance  of  bearing  in 
mind  the  normal  gastric  capacity  of  the  different  ages,  and  of  using  this 
knowledge  to  prevent  the  overfeeding  which  has  produced  so  noticeable 
a  difference  between  the  sizes  of  the  stomach  in  breast-fed  and  artificially 
fed  infants. 

Since  the  development  of  the  methods  of  substitute-feeding  in  connec- 
tion with  milk  modification,  there  is  no  reason  to  suppose  that  when  the 
infant's  stomach  has  been  properly  managed  it  is  any  larger  than  in 
breast-fed  infants. 

The  cause,  however,  which  produces  the  most  uniform  individual  dif- 
ference in  the  gastric  capacity  at  the  same  age  is  the  weight  of  the  infant. 
In  general  it  can  be  said,  the  greater  the  weight  the  greater  the  gastric 
capacity.  A  good  illustration  of  the  correctness  of  this  rule  has  lately 
come  under  our  notice,  where  a  breast-fed  infant  of  twelve  months  with 
a  stomach  normal  in  shape  presented  a  gastric  capacity  of  only  90  to  105 
c.c.  (3  to  3|  ounces).  This  capacity  corresponded  to  its  weight,  4289 
grammes  (9J  pounds),  about  the  average  normal  weight  of  an  infant  at 
eight  or  ten  w^eeks,  rather  than  to  its  age,  which  in  the  average  infant 
would  present  a  gastric  capacity  of  240  c.c.  (8  ounces). 

We  have  also  had  under  our  care  an  infant  of  six  weeks  whose  general 
development  and  weight  corresponded  so  closely  to  those  of  the  normal 
average  infant  of  twelve  weeks  that  it  was  self-evident  that  the  two 
ounces  of  food  which  would  ordinarily  have  been  the  proper  allowance, 
so  far  as  the  age  was  concerned,  was  not  sufficient,  and  that  its  weight 
indicated  a  gastric  capacity  for  an  allowance  of  four  ounces,  which,  in  fact, 
it  took  and  digested  with  the  greatest  ease,  while  with  any  amount  less 
than  the  four  ounces  it  was  never  satisfied. 

In  this  connection  it  is  important  to  note  that  at  autopsies  in  measur- 
ing the  gastric  capacity  it  should  be  done  before  the  stomach  is  separated 


60 


PEDIATRICS. 


I'roiu  its  iiiesenteric  attachiueiit,  as  othenvise  it  is  easily  stretched  by  the 
fluid  introduced,  and  Avill  then  show  a  greater  capacity  than  would  be 
within  the  normal  limits  during  lite.  In  looking  at  the  following  Dlustra- 
tions,  which  represent  the  actual  sizes  of  a  number  of  stomachs  which  have 

Fig.  19. 


Stoma<"h  of  infant  2V>  (\ayf  rilri,  natural  size.     Gastric  capacity,  2.'>  c.,?.     'Weig^ht,  4noo  erammes 


come  under  my  observation,  it  is  interesting  also  to  note  the  different 
shapes  which  th:se  stomachs  represent,  as  some  of  tliem  are  very  differ- 
ent from  the  usual  classical  figures  represented  in  books.     So  far  as  could 


fiG.  20. 


Stomach  of  infant  5  days  oM,  natural  size.     Gastric  ca|iacity,  25  c.c.     Weight,  .''.WJO  grammes. 


be  ascertained,  these  shapes  did  not  occur  from  any  especial  disease,  such 
as  would  influence  the  outline  of  the  stomach. 

On  examining  Fig.  8  (page  34)  and  Figs.  1 9  and  20  it  is  clear  that  one 
cannot  always  depend  on  an  infant's  weight  for  determining  its  gastric 
capacity  in  the  early  days  of  life.   -  Thus,  the  weights  of  2500  grammes. 


Frr,.  2i. 


Stomach  of  infant  7  davs  nl.i    iiatur 


'>-iirh.r  .  lew).     Gastric  capacity,  40  c.  c.     Weight 

.1,'raiunies. 


Fig.  22. 


Stomach  of  infant  12  days  old,  distended  to  hold  SO  c.c.    Natural 


gastric  capacity ,  40  e.t. 


NORMAL    DEVELOPMENT. 


61 


3000  grammes,  and  4000  grammes  all  had  the  same  gastric  capacity  of 
25  c.c.  Again,  the  weight  of  2700  grammes  had  a  greater  capacity,  40  c.c, 
than  the  weights  of  3000  and  4000  grammes.  One  must,  however,  also 
allow  that  there  might  be  an  error  in  measuring  the  gastric  capacity. 

No  rules  for  growth  can  be  deduced  from  this  very  limited  number 
of  cases.     The  significance  of  these  figures  will  be  understood  a  little  later 

Fig-  28. 


stomach  of  infant  5  months  old  (posterior  view).     AVeight,  6000  grammes.     Distended  to  hold  22-t 
Xatural  gastric  capacity,  120  c.c.    S  marks  the  spleen  ;  P  the  pancreas  ;  D  the  duodenum. 


when  Hie  feeding  of  the  early  days  of  life  is  discussed.  Fig.  22  represents 
the  stomach  of  an  infant  twelve  days  old.  It  represents  the  usual  shape 
and  position  of  the  stomach  in  early  life,  and  has  been  distended  beyond 
the  limit  of  its  normal  capacity  to  sliow  the  great  elasticity  of  the  ventric- 
ular walls  already  referred  to.  The  gastric  capacity  was  about  40  c.c. 
(11  ouncesj  ;  when  distended  it  held  80  c.c.  (2f  ounces). 


62  PEDIATRICS. 

Fig,  23  shows  the  stomach,  duodentmi,  spleen,  and  pancreas  of  a 
well-developed  infant  five  months  old. 

Fig.  24  shows  the  stomach  of  an  infant  seven  months  pld  and  weighing 
5500  grammes  (12  pounds).  Its  capacity  is  220  c.c.  (7 J  ounces),  which 
corresponds  to  its  age  rather  than  to  the  weight,  which  13  that  of  an  infant 
four  months  old. 

Another  stomach  taken  from  an  infant  also  seven  months  old,  but 
whose  weight  was  that  of  an  infant  four  months  old,  had  a  capacity  of 
150  c.c.  (5  ounces),  which  corresponded  to  its  w^eight  rather  than  to  its  age. 

Fig.  25  shows  the  stomach  of  an  infant  nineteen  months  old  and 
weighing  6270  grammes  (13|  pomids).  Its  capacity  is  about  300  c.c. 
(10  ounces). 

According  to  these  figures  the  gastric  capacity  in  the  third,  fourth,  and 
fifth  months  may  appear  rather  small,  and  considerable  dififerences  will 
arise  in  the  measurements  by  different  observers.  This,  however,  only 
emphasizes  the  fact  that  the  problem  of  gastric  capacity  has  not  been 
solved  by  any  system  of  measurement.  "When  all  observers  have  agreed 
to  make  use  of  a  mathematically  precise  and  constant  pressure  in  measur- 
ing the  stomach,  we  may  possibly  arrive  at  more  uniform  results.  Even 
then  the  degree  of  elasticity  ^\i\\  be  foimd  to  differ  so  greatly  in  the  iiidi- 
\idual  stomach  that  most  diverse  measurements  will  result. 

There  is  no  doubt  that  the  value  of  these  calculations  lies  in  making 
us  recognize  evident  changes  in  the  acti^ity  of  gro\\ih  at  certain  periods, 
in  making  us  allow  that  great  differences  arise  irrespective  of  age  and 
w^eight,  in  mi  pressing  us  with  the  fact  that  the  gastric  capacity  has  been 
over-  rather  than  under-estimated,  and  in  insisting  that  more  exact 
clinical  observations  should  be  employed  to  reinforce  our  anatomical  and 
physiological  data. 

Through  the  aid  of  a  milk  laboratory  one  may  adapt  exactly  to  the 
apparent  needs  of  the  infants,  as  well  as  to  their  age  and  weight,  the 
amounts  of  food  on  wliich  they  have  seemed  to  thrive. 

The  follo^ving  figures  represent  the  average  amounts  of  food  taken  at 
different  periods  during  their  first  year  by  three  hundred  and  forty-one 
infants.  They  were  all  well  and  strong,  of  average  weight,  and  all  were 
thriving  and  steadily  gaining  during  the  year.  They  received  only  stated 
amounts  of  food  carefully  ordered  by  prescription  at  the  milk  laboratory, 
and  were  watched  "s\1th  the  greatest  care  to  see  when  they  e^■idently  were 
hungry  enough  to  have  the  total  amount  of  their  food  increased.  Of 
course  the  opportunity  for  exact  work  is  almost  unlimited  where  one  has 
a  milk  laboratory  at  his  command,  and  it  has  therefore  seemed  to  me  that 
this  method  of  determining  the  gastric  capacity  is  an  unusually  good  one, 
and  one  which  has  never  thoroughly  been  carried  out  before.  The  fol- 
lowing table  explains  the  significance  of  the  general  figures.  It  shows 
the  necessity  for  frequent  and  great  increase  of  the  total  amount  in  the 
first  four  or  five  months,  the  comparative  quiescence  of  growth  in  the 


NORMAL   DEVELOPMENT.  63 

sixth,  seventh,  and  eighth  months,  and  the  increase  again   in   the   ninth 
and  tenth  months  : 

TABLE  11. 

•  Three  Hundred  and  Forty-one  hifcmtsfed  at  the  Milk  Laboratory. 

j^„e                                                                Number  of  Cases  for  Average  Amount  of  Food  at 

each  Age.  each  Feeding. 

C.c.  Ounces. 

Birth 4-5  29.4            0.98 

4  weeks 76  70.5            2.35 

8  weeks , 84  96.6             3.22 

12weeks 97  118.8            3.96 

16  weeks 87  137.0            4.57 

20  weeks 86  158.4            5.28 

6  months 73  171.3            5.71 

7  months 56  185.4            6.18 

8  months 54  208.5            6.95 

9  months 45  226.2             7.54 

10  months ' 33  238.8             7.89 

11  months 28  242.0             8.07 

In  this  table  the  same  infant  has  of  course  been  recorded  a  number  of  times  at  different 


The  whole  question  of  gastric  capacity  is  so  closely  connected  Avith  the 
subject  of  infant  feeding  that  it  can  be  spoken  of  in  detail  later,  when  it 
will  be  seen  to  be  of  infinite  importance  in  our  attempts  to  regulate  the 
substitute-feeding  of  infants. 

Intestine. — Small  Intestine. — During  the  first  month  after  birth,  it 
may  be  reckoned  that  the  small  intestine  will  grow  about  tAvo  feet  (about 
*sixty-on8  centimetres),  and  a  like  rate  of  growth  may  usually  be  recorded 
at  the  end  of  the  second  month  of  extra-uterine  life  ;  but  after  that  period 
its  dcA^elopment  proceeds  in  a  most  irregular  manner.  Thus,  in  a  child 
of  one  year  the  small  intestine  measured  eighteen  feet  (about  five  hundred 
and  forty-nine  centimetres),  while  in  another,  aged  two  years,  the  length 
was  only  thirteen  feet  eight  inches  (four  hundred  and  seventeen  centi- 
metres). Again,  m  a  child  aged  six  years  the  small  intestine  was  no 
less  than  twenty-one  feet  (about  six  hundred  and  forty  and  five-tenths 
centimetres)  in  length,  while  in  another  child,  eleven  years  of  age,  its 
length  was  fourteen  feet  (about  four  hundred  and  tAventy-seven  centi- 
metres). 

According  to  Treves,  the  great  variations  Avhich  appear  so  early  in  the 
length  of  the  small  intestine  bear  no  relation  to  the  groAvth  of  the  child. 
Thej^robably  depend  on  the  diet.  Not  only  the  quantity  but  the  quality 
of  the  food  is  an  important  factor  in  the  growth  of  the  intestine.  The 
amount  of  residue,  also,  and  the  more  or  less  irritating  qualities  of  the 
food,  must  all  have  their  effect. 

Peyer's  patches  are  found  very  early.  We  have  seen  them  at  three 
days  and  again  at  thirteen  days. 


64  ri:i)i.\Ti;i('s. 

Ill  aiiotln-T  fcise,  sixteen  iiioiitli.s  did,  Peyer'.s  patches  were  IoiiikI.  ;iikI 
one  of  them  was  five  inelies  long. 

Large  Intestine. — Treves  has  also  observed  tliat  up  to  three  or  even 
four  months  tlie  leii^Hli  remains  the  same,  but  that  nevertheless  a  remark- 
able chan^'e  occurs.  This  is  that  the  large  intestine  grows  at  the  expense 
of  the  sigmoid  flexure,  which  at  birth  is  nearly  one-half  of  Hk^  large  intes- 
tine, while  at  four  months  it  has  assumed  about  its  permanent  proportion. 
Treves  found  the  large  intestine  to  measure  at  one  year  two  feet  and  six 
inches  (about  seventy-six  centimetres) ;  at  six  years  about  three  feet  (about 
ninety-one  and  five-tenths  centimetres) ;  and  at  thirteen  years  about  three 
feet  and  six  inches  (about  one  hundred  and  seven  centimetres). 

Cceeum  and  Ascending  Colon. — In  about  thirty-five  observations  on 
children  under  four  years  of  age,  most  of  them  new-born  infants,  the 
caicum  was  found  in  about  thirty  cases  to  range  from  the  right  lumbar 
region  to  the  lower  ijart  of  the  ihac  fossa.  It  was  very  frequently  found 
at  the  junction  of  the  rather  vague  lumbar  and  iliac  regions.  More  or  less 
would  usually  be  found  between  two  parallel  horizontal  lines,  one  at  the 
level  of  the  highest  pohit  of  the  crest  of  the  ilium  and  the  other  at  its 
anterior  superior  spinous  process.  In  five  cases  the  ciBcum  was  either  in 
the  right  iliac  fossa  or  over  the  true  pelvis,  the  fact  being  that  it  was  so 
fi-ee  as  to  have  no  fixed  position.  It  is  comparatively  recently  that  the 
truth  has  been  recognized  in  America,  England,  and  France  that  normally 
the  ctBCum  is  at  every  age  completely  invested  by  the  peritoneum,  and 
that  the  idea  that  a  large  part  of  the  posterior  surface  rests  on  areolar 
tissue  without  any  intervening  serous  membrane  is  baseless,  except  in 
rare  instances. 

In  young  children  the  ascending  colon  differs  in  some  respects  from 
that  of  the  adiill.  Owing  to  the  high  position  of  the  caecum,  to  say  noth- 
ing of  tlie  relatively  greater  size  of  the  liver,  it  is  ver}'  short.  There  is 
no  question  tliat  the  ascending  colon  much  more  frequently  has  a  mesen- 
tery than  in  tlie  adult,  and  also  that  a  relatively  larger  portion  of  the  part 
above  the  ciecum  is  also  invested  with  peritoneum  so  as  to  be  absolutely 
free.  Dwiglit  believes  tliat  the  c;ecum  of  the  infant  and  that  of  tlie  young 
child  are  nuich  more  movable  than  that  of  the  adult,  and  are  also  usually 
situated  higher. 

Vermifona  Appendix. — The  length  and  direction  of  the  vermiform  ap- 
pendix are  very  variable.  We  have  found  it  six  and  a  half  centimetres  (two 
and  five-eighths  inches)  long  in  a  girl  of  thirteen  days,  five  and  three-tenths 
centimetres  (two  and  one-eighth  inches)  in  one  of  three  years,  eight  centi- 
metres (three  and  one-quarter  inches)  in  one  of  ten  months,  and  seven 
and  a  half  centimetres  (three  inches)  in  a  girl  eleven  weeks  old.  It 
would  appear  from  Treves's  researches  that  the  foetal  shape  of  the  caecum 
is  that  of  a  pouch  hanging  down  from  the  point  of  junction  of  the  small 
and  the  large  intestine  and  continued  into  the  appendix,  -which  grows 
symmetrically  from  tlie  middle.     Later,  however,  an  irregular  growth  of 


NORMAL  DEVELOPMENT.  65 

one  side  of  the  caBCuni  generally  leaves  the  origin  of  the  appendix  near 
the  end  of  the  ileum.  Dwight  has  found  that  this  condition  usually  occurs 
in  the  child.  The  position  and  direction  of  the  appendix  are  most  uncer- 
tain. It  is,  however,  as  a  rule,  on  the  posterior  side  of  the  csecum.  Its 
little  mesentery  passes  to  its  beginning  from  the  caecum  and  is  only  ex- 
ceptionally attached  to  the  walls  of  the  abdomen  or  pelvis. 

The  importance  of  the  lymphatic  glands  about  the  caecum  as  possible 
starting-points  of  inflammation  is  very  great.  Tuffier  states  that  the  lym- 
phatics of  the  front  of  the  caecum  follow  the  anterior  ileocaecal  artery  to 
empty  into  two  glands  which  he  has  found  constantly  in  the  superior  ileo- 
caecal fold,  and  which  are  very  distinct  in  the  child.  The  posterior  glands 
are  also  found  constantly  on  the  posterior  and  inner  wall  of  the  ceecum 
itself  beneath  the  peritoneum.  They  usually  form  a  group  of  from  three 
to  six. 

Sigmoid  Flexure. — In  some  cases,  according  to  Dwight,  the  sigmoid 
flexure  is  obviously  very  long,  in  others  apparently  of  about  the  adult 
relative  proportions.  Even  in  infants,  in  whom  the  sigmoid  flexure  does 
not,  as  a  rule,  seem  large,  it  often  has  a  relatively  broad  mesentery,  allow- 
ing free  displacement. 

Descending  Colon. — As  is  well  known,  the  descending  colon  usually 
has  no  mesentery,  but  still  one  is  often  found.  Lesshaft,  in  his  observa- 
tions made  on  subjects  of  many  different  ages,  found  it  once  in  six  times. 
Dwight,  in  rather  more  than  twenty  infants,  found  a  mesentery  to  the 
descending  colon  in  about  half  the  cases.  Lesshaft  found  a  mesentery 
less  often  in  young  subjects  than  in  others.  A  great  part  of  the  large 
intestines  in  infants  is  less  fixed  than  in  adults. 

TEMPERATURE.— The  temperature  of  the  infant  at  term,  although 
varying  within  a  slight  limit,  is  usually  slightly  raised.  Very  soon,  how- 
ever, as  would  be  expected  from  the  tax  which  is  immediately  made  on 
its  vitality  by  so  many  new  surroundings,  the  temperature  falls  rather 
below  the  normal  adult  standard.  In  about  a  week  the  normal  infant  has 
recovered  its  equilibrium,  and,  if  its  nutriment  has  also  been  properly 
adapted  to  its  digestive  power,  it  usually  presents  the  average  normal 
adult  temperature,  36.8°  C.  (98.2°  F.). 


TABLE  12. 

Temperature  of  Infant  at  Term. 

At  birth 37.2°  C.  (99°  F.). 

Within  an  hour 36.1°-35.5°  C.  (97°-96<'  P.). 

In  about  a  week 36.8°  C.  (98.2°  F.). 


These  figures  are  the  average  of  a  large  number,  and  are  subject  to 
^reat  variations,  as  is  seen  on  comparing  them  with  a  number  of  observa- 


66 


I'KDIATl'.U'S. 


tions  undertaken  at  my  request  by  Dr.  C.  W.  Townsend  at  the  Boston 
Lying-in  Hospital : 

'f  ABLE  13. 
'fowih'iend' s  Temperature  Observations. 


j\pg  Temperature. 

Idav .97.2°  0.  ('.i'.i°  F.). 


2  days. 
.5  days . 

5  days. 

6  days. 

7  days. 
7  days. 
7  davs , 


;;7.3°  C.  (u;t.2°  ¥.). 
?,6.(;°  C.  (',18°  F.). 
37.5°  C.  (99.5°  F.). 
37.3°  C.  (99.1°  F.) 
37.5°  C.  (99.5°  F.). 
87.2°  C.  (99°  F.). 
37°  C.  (98.5°  F.). 


Age.  Temperature. 

9  days 37.4°  C.  (99.4°  F. ). 

9  days 37.1°  C.  (98.8°  F.). 

9  days 30.9°  C.  (98.4°  F. ). 

10  days 37.1°  C.  (98.8°  F.). 

13  days 37.2°  C.  (99°  F.). 

13  days 37.3°  C.  (99.2°  F.), 

IG  days 37.3°  C.  (99.2°  F.). 

20  days 37.3°  C.  (99.2°  F, ). 


PULSE. — The  pulse  in  uterine  life  is,  as  a  rule,  somewhat  higher  in 
girls  than- in  boys,  the  former  being  about  130  to  140,  and  the  latter  120 
to  130.  Anything  over  130  points  towards  the  female  sex,  but  these  fig- 
ures as  a  means  of  distinguishing  the  sexes  before  birth  are  not  to  be 
relied  upon.  At  birth  the  pulse  soon  falls  somewhat,  and  may  be  quite 
irregular.  This,  as  a  rule,  is  merely  wdiat  we  should  expect  would  be  the 
result  of  the  sudden  and  great  change  which  has  taken  place  in  the  circu- 
latory iiiechanism,  and  of  the  additional  force  Avhich  the  heart  is  called 
upon  to  supply  Avhen  it  becomes  the  central  station  from  which  the  blood 
is  propelled.  The  lungs  also  are  scarcely  ready  to  perform  at  once  their 
function,  and  are  often  somewhat  more  of  an  obstruction  than  an  aid  to 
the  blood-current.  The  pulse  in  early  life,  especially  during  the  first  year, 
varies  very  much,  but,  as  a  rule,  allowing  that  the  girl's  pulse  is  usually 
more  rapid  than  the  boy's,  the  following  table  represents  very  well  what 
may  be  expected  in  males. 


TABLE  14. 

Pulse-Rate  for  Males. 
.  Pulse-Beats  per  Minute. 

Earlv^^eeks 120  to  140 

Until  2d  year •  •    ^  J*^' 

2  to  3  years 1*^'*^ 

5  to  8  years • -"^ 

From  the  eighth  year  up  to  puberty  the  pulse  gradually  acquires  the 
adult  rate.  The  pulse  in  children  varies  greatly  under  the  many  nervous 
influences  which  are  continually  affecting  it  in  early  life. 

Townsend  has  also  made  a  record  of  the  pulses  taken  in  the  same 
infants  whose  temperatures  were  recorded  in  Table  13.  They  do  not 
especially  correspond  with  the  general  averages,  but  are  w^hat  may  be 
expected  in  cases  seen  at  random. 


NORMAL    DEYELOPMEXT.  67 

T.1BLE  15. 

Tou-iisencV s  PuUe  Observations. 

Age.  Quiet.  Cn-ing. 

1  day 1.3U  i.56 

2  daj-s 120  1.56 

6  days 1:52  164 

6  days 160 

6  days 152 

7  days ,  120  154 

7  days I60 

7  days 152 

9  days 148 

9  days 160  180 

9  days 156 

10  days 1-52 

13  days 1.36 

13  days 168 

16  days 168  172 

20  days 168 

RESPIRATION. — The  respiration,  although  quicker  in  early  life  than 
in  adults  and  corresponding  somewhat  to  the  pulse,  assumes  the  equilib- 
rium of  a  later  period  of  development  much  earlier  than  is  found  to  be 
the  case  with  the  pulse.  It  varies  with  changes  of  temperature  and  with 
excitement,  and  has  its  rhythm  much  more  easily  affected  by  diseased 
conditions  than  in  later  life.  The  following  table  represents  fairly  ^\-ell 
what  is  usually  found  on  counting  the  respirations  when  a  child  is  quiet : 

TABLE  16. 

Iiespira.tion.s. 
Age.  Respirations  per  Minute. 

At  birth 45 

Until  the  3d  year , 1-5  tu  40 

3  to  5  years 25 

The  followmg  is  the  record  made  from  observations  on  a  healthy  male 
eight  months  old,  when  he  was  lying  quietly  on  his  nurse's  lap  : 

The  type  of  respiration  was  decidedly  abdomiuaL  Counting  the  respirations  by 
the  rise  and  fall  of  the  ensiform  cartilage,  which  stood  out  quite  distinctly,  the  respi- 
rations varied  from  50  to  70  in  the  minute.  They  were,  also,  quite  irregular,  and  by 
making  with  a  pencil  an  upward  stroke  for  every  inspiration,  a  down^vard  stroke  for 
every  expiration,  and  a  horizontal  line  for  every  pause,  the  same  lack  of  rhythm  was 
found  that  appeared  in  the  infant  at  term,  described  on  page  36,  and  also  the 
rhythm  corresponding  to  that  of  the  infant  nine  months  old  which  is  described  on 
page  52. 

Townsend  has  also  observed  for  me  the  respiration  of  four  healthy 
infants  at  the  Lying-in  Hospital,  with  the  following  results : 

TABLE  17. 

1.  Age,  1  hour Respirations,  48  to  56.  (Awake.) 

2.  Age,  2  days "  30  to  52.  (Asleep. ) 

3.  Age,  3  days "        24,32,44.  (Asleep.) 

4.  Age,  C  days ««  28  tu  40.  (Crying.) 


68  PEDIATRICS. 

The  respiration  in  all  these  cases  was  very  irregular,  and  both  ab- 
dominal and  thoracic  in  type.  In  the  baby  two  days  old  the  respiration 
was  chiefly  abdominal. 

HEIGHT. — The  average  height  of  the  male  infant  at  term  is,  accord- 
ing to  a  large  number  of  measurements  made  by  Quetelet,  Vierordt,  and 
others,  about  49.5  cm.  (19|  inches).  These  figures  correspond  very  closely 
to  those  which  we  have  ourselves  measured.  Insufficient  nourishment 
and  improper  food,  especially  as  represented  in  rhachitic  children,  seem 
to  retard  the  growth,  while  on  the  contrary,  the  various  fevers  seem  to 
increase  the  activity  of  growth  in  length,  while  decreasing  the  total  weight. 
In  the  first  three  or  four  months  the  growth  is  proportionally  rapid  to  that 
in  the  latter  part  of  the  first  year.  In  like  manner  the  activity  is  greater 
in  the  first  month  than  in  the  second,  and  in  the  second  than  in  the  third, 
becoming  still  less  in  the  fourth,  fifth,  and  six  months. 

The  average  increase  for  the  first  month  is  about  4.5  cm.  (1|  in.). 

"  "  "  "  "  second  month  is  about  3.0  cm.  (Hin. ). 

"  "  "  "  "  third  to  the  fifteenth  month  is  about  1  to  1.5  cm.  (i  to  fin. ). 

"  "  "  "  "  first  year  is  about  20  cm.  (8  in.). 

"  "  "  "  "  second  year  is  about  9  cm.  (3Jiu. ). 

"  '•  "  "  "  third  year  is  about  7.4  cm.  (3  in.). 

"  "  "  '(  ((  fourth  and  fifth  J' ears  is  about  6.4  cm.  (2|  in.). 

"  "  "  <<  (t  fifth  to  the  sixth  year  is  about  6  cm.  (2|  in. ) 

The  height  is  about  doubled  in  the  first  six  years,  and  at  fourteen 
years  the  final  height  has  usually  been  attamed  to  within  about  one-twelfth. 
The  height  at  different  ages  will  be  shown  in  comparison  with  the  weight 
on  page  75.     The  growth  in  height  seems  to  be  most  active  in  the  spring. 

WEIGHT. — The  careful  and  systematic  weighing  of  an  infant  gives  us 
the  most  reliable  of  all  data  in  regard  to  its  normal  development.  The 
weight  chart  is  as  important  in  the  management  of  the  dietetics  of  infancy 
as  the  temperature  chart  is  in  the  treatment  of  febrile  affections.  It  is  not 
sufficient  to  know  that  an  infant  is  gaining  in  weight ;  the  point  that  should 
always  be  borne  in  mind  is  whether  it  is  gaining  as  much  as  the  average 
healthy  infant.  To  determine  this  it  is  necessary  to  have  some  ready 
means  of  comparison,  and  it  is  customary  to  make  use  of  a  weight  chart 
such  as  is  given  on  page  72,  showing  the  average  gain  in  weight  of  a  large 
number  of  healthy  infants  in  the  first  year  of  life.  Taking  this  as  a  standard 
one  may  plot  the  weight  curve  of  any  individual  infant. 

The  weight  of  a  healthy  child  is  liable  to  oscillation  within  limits  which 
have  not  been  accurately  determined,  but  it  may  sometimes  amount  to  ten 
or  fifteen  per  cent,  in  a  week.  Children  lose  in  weight  and  regain  their 
loss  in  a  wonderful  manner,  so  easily  are  they  affected  by  even  slight 
physical  disturbances,  and  so  great  are  their  recuperative  powers.  The 
weight  of  boys,  as  a  rule,  is  somewhat  greater  than  that  of  girls  at  birth, 
and  remains  greater  up  to  the  age  of  puberty,  when  the  girl  rapidly  over- 
takes the  boy,  surpasses  him,  and  becomes  a  developed  woman  very  soon. 


NORMAL  DEVELOPMENT.  69 

while  the  boy  does  not  become  a  man  until  some  years  after  puberty. 
This  fact  is  exemplified  in  the  table  on  page  76,  whicli  shows  that  the  girls 
have  surpassed  the  boys  in  their  height  at  the  eleventh  year,  and  in  their 
weight  at  the  twelfth  year,  when  they  are  found  to  be  taller  and  heavier 
than  the  boys,  as  is  the  case  also  in  the  thirteenth  and  the  fourteenth  year. 
The  normal  average  weight  of  quite  a  number  of  infants  at  term  is  for 
males  3250  grammes  (T|  pounds),  and  for  females  3150  grammes  (7 
pounds) ;  many  individual  cases  occur,  however,  Avhere  the  weight  is  either 
greater  or  less  than  these  figures,  and  yet  the  infant  is  healthy.  The  in- 
crease in  weight  is  usually  in  direct  proportion  to  the  original  weight,  and 
if  the  original  weight  is  small  the  gain  is  usually  correspondingly  small. 
This,  however,  is  only  a  general  rule,  for  at  times  infants  of  light  weight 
are  met  with  whose  gains  are  remarkably  large,  and  often  surpass  those  of 
infants  with  a  heavier  initial  birth  weight.  During  the  first  three  or  four 
days  of  life  there  is  usually  a  loss  in  weight,  and  the  original  weight  is  in  a 
large  number  of  cases  regained  only  in  the  second  week.  If  it  is  not 
regained  by  the  third  week,  we  should  consider  that  it  is  a  warning  that  the 
nutrition  of  the  mfant  is  at  fault,  and  that  especial  measures  should  be  taken 
to  increase  its  vitality.  This  initial  loss  of  weight  is  usually  designated  as 
physiological.  It  often  amounts  to  from  270  to  300  grammes  (9  to  10  ounces) 
and  can  be  accounted  for  only  partially  by  natural  physiological  causes. 
The  additional  loss  is  evidently  pathological,  and  is  to  be  so  regarded,  in 
order  that  we  should  endeavor  to  prevent  an  additional  tax  on  the  infant's 
vitality  at  a  time  when  any  tax  whatever  should  be  regarded  as  serious. 
Townsend  has  made  some  interesting  investigations  on  this  loss  of  weight  at 
the  Boston  Lying-in  Hospital,  which  show  that  the  infants  of  primiparselose 
about  45  grammes  (1|  ounces)  more  than  those  of  multiparoe  ;  also,  deduct- 
ing 45  grammes  (IJ  ounces)  as  the  average  loss  from  removal  of  the  vernix 
caseosa,  the  meconium  still  remaining,  that  the  loss  in  weight  is  reduced 
to  247  grammes  (8i  ounces)  in  the  infants  of  primiparae,  and  to  222 
grammes  (7f  ounces)  in  those  of  multiparse.  The  whole  loss  should  in- 
clude the  meconium,  which  is  computed  to  weigh  about  60  to  70  grammes 
(2  to  2^  ounces),  so  that  a  loss  of  from  90  to  150  grammes  (3  to  5 
ounces),  which  includes  also  the  urine,  on  the  first  day,  can,  in  a  very 
general  way,  be  admitted  to  be  purely  physiological.  Townsend' s  figures 
also  show  that  although  the  infants  of  primiparse  lose  more  and  are  slower 
to  recover  the  loss  than  are  those  of  multiparae,  yet  after  the  second  week 
they  overtake  and  keep  pace  with  the  latter.  The  whole  question  is 
simply  one  of  nutrition,  it  being  well  known  that  the  milk  of  primiparse  is 
somewhat  longer  in  acquiring  its  equilibrium  than  that  of  multiparte,  but 
that  finally  it  is  equally  nutritious.  It  was  also  found  that  the  presence 
of  the  colostrum  corpuscles  in  the  milk  had  something  to  do  with  the  loss 
or  with  the  failure  to  gain.  Where  the  colostrum  persisted  the  infants  lost 
more  than  when  it  speedily  disappeared.  The  colostrum  should  normally 
disappear  in  the  first  week.     Where  its  presence  is  prolonged  into  the 


70  PEDTATRICS. 

third  week,  the  infants  do  not  thrive.     Three  cases  at  the  hospital  illus- 
trated this  point :  all  the  mothers  seemed  healthy  and  had  plenty  of  milk. 

(1)  Multipara — no  culostfuin  on  third  daj', — infant's  loss  8  ounces. 

(2)  Multipara — colostrum  until  ninth  day, — infant's  loss  16  ounces. 

(■3)   Priinipara — colostrum  until  thirteenth  day, — infant's  loss  14  ounces. 

The  average  loss  in  five  infants  of  multiparse  in  whose  milk  the  colos- 
trum was  absent  by  the  fifth  or  sixth  day  was  10  ounces. 

The  whole  nervous  system  of  the  young  child  is  much  more  active 
and  excitable  than  that  of  the  adult.  The  brain,  for  instance,  besides  being 
fifteen  times  as  large  proportionately  in  the  infant  as  in  the  adult,  increases 
^^dth  much  greater  rapidity  up  to  the  age  of  seven  years  than  at  any  other 
period.  In  connection,  probably,  with  the  constructive  labors  of  the 
growing  tissues  is  the  activity  of  the  lymphatic  system.  The  absorption 
of  oxygen  is  said  to  be  relatively  more  rapid  than  the  production  of  car- 
bonic acid, — that  is,  there  is  a  continued  accumulation  of  capital  in  the 
form  of  oxygen-holding  compounds.  The  food  represents  so  much  poten- 
tial energy,  but  it  must  be  converted  into  tissue  before  the  energy  can  be- 
come vital,  and  in  such  conversion  a  large  amount  of  molecular  energy  must 
be  expended.  The  metabolic  activity  is  more  pronounced  in  the  infant 
than  in  the  adult,  and  is  expended  not  so  much  on  the  energy  required  in 
the  external  world  as  for  the  rapidly  increasing  mass  of  tissue.  Another 
reason  for  the  presence  of  more  active  metabolism  in  the  infant  than  in 
the  adult  is  the  necessity  of  rapid  molecular  interchange  to  keep  up  the 
temperature.  The  infant  having  the  smaller  body,  and  yet  the  relatively 
larger  surface  (the  extent  of  skin  thus  being  proportionately  greater),  it 
loses  more  heat  proportionately  than  does  the  adult,  and  thus  suffers 
more  easily  from  changes  of  temperature  (Foster). 

Disturbances  of  the  nutritive  process  from  these  conditions  very  easily 
arise,  and  the  process  of  assimilation  is  much  more  important  than  in 
adult  life,  for  the  child's  activity  implies  a -greater  consumption  of  nutri- 
ment in  the  form  of  food  or  tissue.  The  child's  equilibrium  is  thus  much 
more  easily  disturbed  than  the  adult's,  and  this  creates  a  greater  suscepti- 
bility to  disease  and  less  power  to  resist  external  influences.  This  is  well 
exemplified  by  the  rule  that  the  younger  the  individual  the  greater  the 
mortality.  There  are  three  times  as  many  deaths  in  the  first  half  of  the 
first  year  as  in  the  second  half,  and  a  large  proportion  of  those  dying  in 
the  first  half-year  die  in  the  first  month.  Of  those  dying  in  the  first 
month,  death  occurs  in  a  large  proportion  in  the  first  week.  A  consider- 
able number  of  the  deaths  which  occur  in  the  early  weeks  of  life,  espe- 
cially in  the  first  week,  are  from  asthenia.  These  facts  are  very  significant 
in  connection  Avith  the  child's  loss  of  weight  in  the  early  days  of  life  over 
that  which  we  have  just  descril^ed  as  being  physiological.  Lack  of  suf- 
ficient nourishment  and  an  unstable  equilibrium  are  the  factors  in  the 
problem  wdiich  represent  this  early  loss  of  weight.     These  conditions  are 


NORMAL    DEVELOPMEXT.  71 

enhanced  by  the  state  of  the  mother,  who,  exhausted  by  the  process  of 
labor,  is  not  able  to  supply  a  food  for  her  infant  which  is  adapted  to  its 
sensitive  and  incompletely  developed  digestive  function.     (Evetsky.) 

In  addition  to  these  manifest  causes  for  loss  of  weight,  we  must  con- 
sider that  the  new-born  infant  is  much  more  susceptible  to  external  im- 
pressions than  when  after  the  first  weeks  its  various  functions  have 
become  adapted  to  their  new  surroundings. 

The  following  case  exemplifies  the  practical  "bearing  of  what  has  just 
been  said  : 

A  male  infant  was  born  December  16  at  term.  It  was  healthy  and  vigorous,  and 
gave  no  evidence  of  organic  disease.  The  mother,  a  multipara,  strong  and  healthy, 
was  twenty-eight  years  of  age.  Her  other  children  were  living  and  healthy.  On  the 
third  day,  December  19,  the  infant  had  a  slight  attack  of  icterus  neonatorum,  which 
disappeared  in  twenty-four  hours.  On  the  fifth  day,  December  21,  the  weather  was 
very  cold  and  bleak,  but  the  infant  was  taken  to  church  and  christened.  The  church 
was  warm  and  the  infant  reasonably  well  protected  from  cold,  but  there  -was  a  large 
number  of  people  present,  and  an  unusual  amount  of  noise.  The  infant,  on  being 
taken  home,  immediately  began  to  show  symptoms  of  asthenia,  and  on  the  following 
day  was  found  to  be  cyanotic  and  breathing  rapidly,  with  a  subnormal  temperature 
and  no  apparent  organic  disease.  It  died  in  the  afternoon.  The  asthenia  seemed  to 
be  produced  by  too  early  exposure  to  change  of  temperature,  light,  and  sound. 


As  a  rule,  the  average  daily  gain  in  the  first  two  months  should  not 
be  below  twenty  grammes  (two-thirds  of  an  ounce).  It  has  been  found 
at  the  Infants'  Hospital  that  if  the  gain  is  less  than  this  the  infant,  as  a 
rule,  is  being  badly  nourished,  is  sick,  or  is  going  to  be  sick.  A  cessation 
in  the  gain  in  weight  or  a  progressive  loss  in  weight  often  gives  warning  of 
an  impending  illness  before  any  other  symptoms  are  present.  There  are, 
of  course,  exceptions  to  this  rule,  and  it  should  be  clearly  borne  in  mind 
that  observations  of  weight  including  only  that  of  two  or  three  days  are 
very  misleading,  and  that  it  is  the  week's  weight  which  gives  us  the  fairest 
idea  of  loss  or  gain.  Thus,  one  frequently  finds  infants  showing  a  daily 
gain  of  only  five  or  ten  grammes  (one-sixth  or  one-third  ounce),  or  even 
losing  fifteen  or  thirty  grammes  (one-half  or  one  ounce)  on  one  day, 
and  then  gaining  one  hundred  to  one  hundred  and  fifty  grammes  (three 
and  one-third  to  five  ounces)  on  the  next  day.  From  this  it  will  be 
readily  understood  that  we  should  obtain  from  one  day's  observation  too 
low  and  on  the  next  day  too  high  an  estimate  of  the  nutrition.  By  the 
end  of  the  week,  however,  the  weights  usually  equalize  each  other,  and 
we  have  fairly  correct  figures  to  guide  us.  The  following  table  shows 
about  what  would  be  expected  of  the  average  infant  as  to  weight  during 
the  first  year.  Girls,  as  a  rule,  gain  less  than  boys,  but  this  is  only  if  they 
are  of  lighter  initial  weight.  The  heavy  girls  make  the  same  large  gains 
as  the  heavy  boys,  but,  as  a  rule,  their  initial  weight  is  smaller  than  that 
of  the  boys,  and  they  therefore  make  smaller  gains. 


72 


PEDIATRICS. 


The  following-  weight  chart  shows  the  progress  in  weight  development 
made  by  an  average  healthy  infant  during  the  first  year  of  life : 


CHART  1. 


INFANT'S  WEIGHT  CHART. 


Weeks.    1    3    5    7    9    11  13  15  17  19  81 


Months.             12           3           4           5           1 
Weeks.    1     3  U    7    Iq  U  iWs  17i  19  21  23  2.5 

7            8            9    .       JO          11          12   13   14  15 

27   29   31  33  i.5  37  39  41   4^  45  47   49  51      5(1  CO  64  Of 

16   17 

1  72I76 

8    19 

20    21    22  23    24 

1       1       1       1       1 
iS8  93  96  100104 

~P 

n..,     _  J            1 

29 

28 

27 

/ 

/ 

^ 

/ 

20 

^ 

/ 

/ 

25 

/ 

; 

/ 

24 

1 

/ 

/ 

23 

i 

— 

/ 

r 

/ 

22 

y 

/^ 

J 

/ 

21 

J 

V 

I  r 

-J^ 

20 

^c_ 

/'^ 

/ 

j^ 

19 

^^'^ 

-^^ 

4^                                                              ^ 

J ^             + 

18 

~y 

y 

j*^ 

__.^:__ __  _     _ 

17 

y. 

/ 

^^ 

16---     -    -                -     i 

16 

J^ 

J 

15 

J 

r 

11 

^ 

J 

13 

J  ^ 

,  ^ 

12 

J_ 

} 

11 

7 

' 

10 

4 

t 

1 

Q—       -J-^            -__       ___            __       __ 

9 

t 

y 

l 

o_        J_ __        _        - 

3 

8        ^ 

^4 

„ 

7 

— 

- 

1 

D               1 

1 

1 

1 

.27  29  31  33  35  37  39  41  43  45  47  49  51      ^%  60  61  63  72  76  SO  84  S8  92  96  100101 

DESIGNECl  BY  J.P,   CROZER  GRIFFITH,  M,  D, 


If  the  above  chart  is  examined  in  reference  to  the  relative  gains  in 


NORMAL    DEVELOPMENT.  73 

weight  in  the  four  quarters  of  the  year,  it  will  be  seen  that  there  is  con- 
siderable variation  in  the  rate  of  development. 

Total  gain  (approximately)  in  Weekly  gain  in 

Grammes.  Pounds.  Grammes.         Ounces. 

First  three  months 2400  5  180  6.2 

Second  three  months 1920  4  148  5 

Third  three  months 1200  2J  92  3.1 

Fourth  three  months 1320  2f  102  3.5 

In  the  first  three  months  the  gain  in  weight  is  most  rapid  of  all ;  in  the 
second  quarter  not  so  marked ;  m  the  third  quarter,  owing  probably  to  the 
fact  that  it  is  the  most  active  period  of  dentition,  the  gain  is  slowest  of  all 
and  for  weeks  there  may  be  an  actual  cessation  of  weight  development ;  in 
the  fourth  quarter  greater  activity  is  manifested. 

If,  therefore,  we  are  comparing  the  influence  of  feeding  on  two  infants, 
one  two  months  old  and  one  seven  months  old,  we  cannot  take  the  average 
gain  per  week  of  the  first  infant  as  a  standard  by  which  to  judge  the  prog- 
ress made  by  the  second,  for.  there  is  in  the  infant  of  two  months  an 
inherent  tendency  to  gain  weight  faster  than  in  the  mfant  of  seven  months. 
Any  comparison  must  be  made  in  reference  to  the  average  healthy  infant 
in  the  same  stage  of  development.  It  is  for  this  reason  that  the  weight 
chart  gives  us  the  most  satisfactory  means  of  determining  what  any  infant 
is  doing  in  its  weight  development. 

A  further  extension  of  such  a  method  of  comparison  and  one  which  is 
more  adapted  for  estimating  the  weight  development  of  one  or  many 
infants  is  to  express  this  weight  curve  of  the  average  healthy  infant  by 
means  of  a  weight  index.     This  index  may  be  expressed  as  follows  : 

The  weight  of  an  infant. 
Weight  Index  = 


Weight  of  the  average  healthy  infant  of  the  same  age. 


If  the  weight  index  is  then  multiplied  by  100  the  result  expresses  in 
per  cent,  the  weight  development  of  the  infant.  The  weight  of  the  aver- 
age infant  at  any  age  may  be  obtained  by  referring  to  the  above  weight 
chart. 

An  infant  whose  birth  weight  and  subsequent  growth  corresponded 
exactly  to  that  of  the  average  infant  would  naturally  always  have  a 
weight  development  of  100  per  cent.  As  long  as  this  percentage  devel- 
opment is  maintained  we  know  the  infant  is  gaining  proportionately 
as  fast  as  the  average  infant.  If  the  gain  in  weight  of  such  an  in- 
fant is  slower  than  that  of  the  average  child,  its  weight  development 
becomes  proportionately  less  than  100 ;  if  the  gain  in  weight  is  more 
rapid  than  that  of  the  average  child  its  weight  development  would 
exceed  100. 

If  an  infant  weighs  more  than  the  average  at  birth  its  weight  index  is 
naturally  more  than  1.0,  and  its  weight  development  exceeds  100.     For 


74 


PEDIATRICS. 


example,  following  the  formula  given  above,  an  infant  whose  weight  is  9 
pounds  at  birth  has  a  weight  development  of  120  per  cent. 

In  a  similar  manner  an  infant  weighing  5J  pounds  at  birth  will  have  a 
weight  development  of  only  70  per  cent. 

The  weight  index  enables  us  to  express  hi  defmite  percentages  the 
relative  progress  made  by  infants  of  chfferent  degrees  of  development.  By 
means  of  it  we  may  also  compare  a  gain  or  loss  in  percentage  development 
of  one  quarter  of  the  year  with  that  of  another  quarter,  in  the  same  infant, 
or  in  two  infants  of  different  ages  whose  nutritive  development  we  are 
comparing. 

In  the  majority  of  cases  of  infants  of  the  dispensary  class  w^e  can  place 
no  reliance  on  the  statements  of  the  parents  as  to  the  birth  weight.  It  is, 
therefore,  rare  to  be  able  to  estimate  with  any  degree  of  certainty  the 
weight  indices  at  birth.  We  can,  how^ever,  w^eigh  such  infants  Avhen  they 
first  come  under  our  observation  and  so  determine  the  weight  indices  at 
the  beginning  of  the  treatment.  Subsequent  w^eighings  will  give  us  the 
means  of  estimating  subsequent  weight  indices  and  of  determining  and 
expressing  in  definite  percentages  the  progress  which  the  infant  is  making 
in  its  w^elght  development  in  comparison  with  that  which  it  showed  wdien 
it  first  came  under  treatment. 

Chart  2  has  been  plotted  to  express  diagramatically  what  has  been 
mentioned  above. 

CHART  2. 


12  Months 


Infaut  C  5 
i 


The  middle  line  ''B"  represents  the  weight  curve  of  the  average 
healthy  infant.  This  curve  is  taken  as  the  constant  by  which  to  estimate 
the  Aveight  index  of  any  infant.  The  perpendicular  lines  represent  the 
number  of  pounds  the  child  gains  in  the  four  quarters  of  the  first  year. 
The  weight  index  of  such  an  infant  is  1.0,  the  weight  development  100  per 
cent. 

The  upper  curve  "A"  represents  the  theoretical  curve  of  an  infant 
weighing  9  pounds  at  birth,  with  a  resulting  w^eight  index  on.2.  If  such 
an  infant  were  to  maintain  throughout  the  first  year  the  advantage  in 


PLATE  II. 


^k 


■c>" 


Icterus  Neonatorum. 


Red  Bone  Marrow.     Natural  Size- 


Yellow  Bone  ]Marrow.     Three-fourths  Natural  Size. 


Erythema  Neonatorum. 


NORMAL  DEVELOPMENT.  75 

weight  development  with  which  it  starts  out  in  Hfe,  its  quarterly  gains  in 
pounds  would  be  as  are  indicated  in  the  perpendicular  lines.  These  will  be 
seen  to  vary  considerably  from  those  of  the  average  healthy  infant  repre- 
sented in  curve  '•  B." 

In  a  similar  manner  curve  "  C  "  represents  the  theoretical  weight  curve 
of  a  SJ-pound  baby,  with  a  weight  index  of  0.7,  and  the  perpendicular  lines 
show  the  quarterly  gains  in  pounds,  which  would  be  necessary  to  main- 
tain throughout  the  first  year  the  weight  development  with  which  it  starta 
in  life.  These  are  seen  to  be  considerably  less  than  that  of  the  avera^,^ 
healthy  infant. 

Now,  for  example,  if  infant  C  and  infant  A  each  gain  from  the 
sixth  to  the  ninth  month  5  pounds,  instead  of  the  theoretical  gains 
expressed  in  the  perpendicular  lines,  one  will  find  by  working  out  the 
above  formula,  that  the  weight  index  of  infant  C  has  been  raised  to 
0.85,  a  gain  of  15  per  cent,  in  weight  development;  that  the  weight 
index  of  infant  A  has  been  raised  to  1.30,  a  gain  of  10  per  cent,  in 
weight  development.  In  other  words,  although  each  infant  has  gained 
the  same  number  of  pounds  in  three  months,  the  smaller  infant  C  has 
gained  proportionately  5  per  cent,  more  in  weight  development  than  the 
larger  infant  A. 

It  is  not  to  be  supposed  that  every  healthy  infant  weighing  above  nor- 
mal at  birth  and  having  a  weight  development  above  100  will  maintain 
throughout  the  first  year  the  same  percentage  of  development  Avith  which 
it  starts  out  in  life,  some  will  and  others  will  not.  There  is  in  the  major- 
ity of  cases  a  tendency  for  the  line  of  growth  of  these  large  infants  to  dip 
downward  and  gradually  to  approach  the  weight  curve  of  the  average 
child. 

On  the  other  hand  there  is  a  great  tendency  for  the  under-sized  infants, 
if  properly  fed,  to  grow,  relatively  to  their  initial  weight  development, 
faster  than  the  average  child  and  their  line  of  growth  tends  upward  to 
meet  that  of  the  average  infant.  In  judging  the  effects  of  feeding  upon 
two  such  theoretical  cases  as  "  A  "  and  "  B  "  in  the  above  example  it  is 
obviously  unfair  to  take  the  number  of  pounds  gained  in  each  quarter 
by  each  infant  as  the  sole  basis  of  comparison.  A  more  exact  and  scien- 
tific method  is  to  indicate  their  rate  of  growth  in  percentages  of  develop- 
ment. We  may  thus  express  with  clearness  and  in  easily  understood 
terms  their  progress  either  in  reference  to  each  other  or  to  the  average 
healthy  child. 

The  weight  index,  then,  Avhile  not  embodying  any  fixed  law  of  growth 
may  be  used  to  express  in  definite  percentages  the  variations  in  weight 
development  of  an  infant  which  may  occur  as  a  result  of  natural  growth  or 
disease. 

In  the  following  table  the  weights  at  birth,  and  in  the  first,  second, 
and  third  years,  were  taken  without  clothing.  The  ordinarj'  school-clothes 
were  worn  in  the  weighing  from  five  to  fourteen  years  : 


76 


PEDI.VTRTCS. 


The  figures  Cor  birth,  for  five  months  and  Cor  one  year,  represent  our 
investigations,  combined  with  the  figures  wliich  have  already  been  shown. 
Tlie  figiires  for  tlie  second  and  tiiird  years  are  taken  from  a  series  of  in- 
vestigations made  by  Peckham,  of  Milwaukee,  in  the  Report  of  the  AVis- 
consin  State  Board  of  Health  for  1882.  The  figures  for  the  fourth  year 
are  appro.Kimate  averages  taken  from  children  of  three  and  five  years. 
The  figures  from  the  fifth  year  to  the  fourteenth  year  were  taken  from 
Bowditch's  article  on  the  Growth  of  Children,  in  the  Twenty-second  An- 
nual Report  of  the  State  Board  of  Health  of  Massachusetts.  They  repre- 
sent the  average  figures  of  a  large  number  of  school-children. 


TABLE  18. 

Average  Heights  and  Weights  from  Birth  to  Five  Years,  and  of  Boston  School  Boys  and 
Girls,  irrespective  of  Nationality,  from  Five  to  Fourteen  Years. 


Boys. 

Age. 

Girls. 

Height. 

\Veight. 

Height. 

Weight. 

Centimetres. 

Inches. 

Kilogrammes. 

Pounds. 

Centimetres. 

Inches. 

Kilogrammes. 

Pounds. 

49.37 

19.75 

3.25 

7.15 

Birth. 

48.12 

19.25 

3  15 

6.93 

G1.87 

24.75 

6.50 

14.30 

5  months. 

59.12 

23.25 

6.80 

18.86 

73.82 

29.53 

9.54 

20.98 

1  year. 

74.17 

29.67 

9.00 

19.80 

84.55 

33.82 

13.80 

30.36 

2  years. 

82.35 

32.94 

13.31 

29.28 

92.65 

37.00 

15.90 

34.98 

3  years. 

90.77 

36.31 

15.07 

83.15 

98.27 

39.31 

17.27 

37.99 

4  years. 

97.00 

38.80 

16.53 

36.86 

103.92 

41.57 

18.04 

41.00 

5  years. 

103.22 

41.29 

17.99 

39.57 

109.37 

43.75 

20.49 

45.07 

6  years. 

108.37 

43.35 

19.63 

43.18 

114.35 

45.74 

22.26 

48.97 

7  years. 

113.80 

4.5.52 

21.50 

47.80 

119.40 

47.76 

24.46 

53.81 

8  years. 

118.95 

47.58 

23.44 

51.56 

124.22 

49.69 

26.87 

59.00 

9  years. 

128.42 

49.37 

25.91 

57.00 

129.20 

51.08 

29.62 

05.16 

10  years. 

128.35 

51.34 

28.29 

62.28 

133.32 

53.33 

31.84 

70.04 

11  years. 

183.55 

58.42 

81.28 

68.70 

137.77 

55.11 

34.89 

70.75 

12  years. 

189.70 

55.88 

3.5.58 

78.16 

143.02 

57.21 

38.49 

84.67 

13  years. 

145.40 

58.16 

40.21 

88.46 

149.70 

59.88 

42.95 

94.49 

14  years. 

149.85 

59.94 

44.65 

98.23 

Useful  figures  to  remember  are  that  the  initial  weight  is  doubled  at  five 
months  and  a  little  more  than  trebled  at  fifteen  months  ;  that  the  weight 
at  one  year  is  doubled  at  five  years,  and  that  this  weight  is  again  doubled 
at  twelve  years.  There  are,  of  course,  both  gains  and  losses  of  weight 
during  the  year,  the  weight  acting  as  an  index  of  the  disturbances  which 
arise. 

FEET. — According  to  Dane,  the  pad  of  fat  that  fills  the  hollow  under 
the  bones  in  the  infant's  foot  is  designed  to  support  the  arch  until  the 
muscles  are  strong  enough  to  hold  it  by  themselves.  The  fat  in  this  way 
acts  as  a  kind  of  physiological  flat-foot  plate. 

As  soon  as  the  muscles  become  strong  enough  to  protect  the  arch  the 
pad  of  fat  is  no  longer  necessary,  and  is  slowly  absorbevl,  until  by  the 


PLATE  III. 

A.  Intertrigo. 

B.  Seborrhoea  capitis  of  infants. 

C.  Cord,  24  hours  old. 

D.  Cord,  6  days  old. 

Napkins. 

1.  Detritus  of  uric  acid  infarction  (stain  on  napkin  during  early  days  of  life). 

2.  Meconium. 

3.  Color  of  fffices  resulting  from  good  human   breast-milk. 

5.  Crystals  of  uric  acid  and  urate  of  ammonium  (hedgehog  crystals)  taken  from  10. 

6.  Substitute  feeding.     Fat,  2  per  cent.  ;  milk-sugar,  5  per  cent.  ;  proteids,  1  per  cent. 

•7  11  II  11        g  (1  II  g  11  II  J  C 

8.  "  "  "    4       "  "  7       "  "    ,    1 

g  <i  11  11     4        '•  "7         "  '•  1  " 

10.  Detritus  of  uric  acid  infarction  in  excess. 

11.  Bile-stain  on  napkin. 

12.  Color  of  fieces  after  bismuth  3  grains  was  given  every  two  hours  for  six  doses. 

23         u  II        11  11         ^       u  11  u  i« 

14.  "  "        "  "         was  omitted  for  twenty-four  hours. 

15.  Color  on  napkin  commonly  seen,  but  in  this  case  excessive  in  amount  and  patho- 

logical from  uric  acid. 

16.  Color  of  "  clay-colored"  fseces. 

17.  Color  of  the  change  in  milk-fed   (breast  or  otherwise)  infant's  faeces  which  may 

occur  just  before  or  just  after  they  are  passed  (not  necessarily  pathological). 

18.  Pathological  color  as  seen  in  case  described  on  page  814. 
29_  11  11         11  11  .    "  "  11 


PLATE  III. 


NORMAL  DEVELOPMENT.  77 

fourth  or  fifth  year  the  foot  presents  the  same  appearances  found  hi  the 
adult. 

In  a  few  children  the  pad  of  fat  is  found  to  be  wanting,  and  m  many 
of  these  cases  the  arch  is  so  far  obhterated  that  the  tubercle  of  the  scaphoid 
may  even  rest  on  the  ground.  These  latter  are  the  true  cases  of  "  flat- 
foot." 

BONE  MARROW. — The  change  from  the  red  bone  marro^v  of  early 
life  to  the  yellow  marrow  of  a  later  period  begins,  according  to  Minot, 
before  birth,  and  progresses  in  each  bone  from .  the  centre  towards  the 
periphery,  or  in  the  long  bones  towards  the  ends. 

It  begins  earlier  in  the  distal  bones  and  then  goes  on  from  bone  to 
bone  centripetally.  Concernins-  the  exact  time  when  these  changes  take 
place  very  little  is  known,  and  nothing  definite.  Plate  II.,  facing  page  76, 
shows  the  red  and  yellow  bone  marrow. 

SKIN. — As  the  infant  grows  older  the  skin  changes  gradually  to  a  deli- 
cate pinkish  white  in  place  of  the  decided  pink  of  the  early  days  of  life. 

CORD. — The  cord  should  be  carefully  wrapped  in  antiseptic  absorbent 
cotton,  and  no  water  should  be  allowed  to  come  in  contact  with  it.  It 
will  thus  become  dry  sooner,  and  will  gradually  loosen  and  fall  off. 

FUNCTIONS. — The  different  functions  of  the  infant,  like  its  physical 
characteristics,  vary  considerably  as  to  the  time  of  their  development. 
It  is  difficult,  therefore,  to  give  exact  average  figures,  and,  in  fact,  our 
observation  of  individual  cases  has  differed  so  often  from  these  average 
figures  that  we  must  allow  much  latitude  in  stating  the  proper  time  for  an 
especial  function  to  develop.     (See  also  page  — .) 

Voice. — During  the  first  year  of  its  life  the  average  infant  uses  its  voice 
merely  in  crying  to  express  its  discomforts  and  desires.  At  alDout  the 
twelfth  month  it  usually  begins  to  enunciate  single  words,  and  in  the 
middle  or  towards  the  end  of  the  second  year  it  learns  to  form  short  sen- 
tences. Children  vary  very  markedly  as  to  the  time  when  they  really 
learn  to  talk  connectedly,  but  this  is  usually  accomplished  by  the  third 
or  fourth  year,  though  it  is  somewhat  later  before  they  master  the  details 
of  language,  such  as  the  proper  use  of  prepositions. 

Mental  Impressions. — The  infant  seldom  smiles  before  the  fifth  or 
sixth  week,  the  change  of  expression  of  the  mouth  before  that  time  bemg 
usually  an  indication  of  some  chscomfort.  In  individual  cases,  however, 
there  is  no  doubt  that  the  true  smile  of  enjoyment  comes  earlier,  even  by 
the  fourth  week.  The  infant  usually  does  not  recognize  objects  before 
the  sixth  or  eighth  week.  Its  hearing  is  soon  established.  The  fmictions 
of  TOUCH,  TASTE,  aiid  SMELL  are  apparently  more  or  less  developed  at 
birth. 

Lachrymal  Glands. — The  development  of  the  function  of  the  lachry- 
mal glands  varies  considerably,  but  the  infant  will  usually  be  found  to 
shed  tears  when  it  is  three  or  four  months  old.  We  have  known  tears  to 
appear  as  early  as  the  first  month.     They  do  not  at  first  come  every  time 


78  PEDIATRICS. 

the  infant  cries,  so  that  a  number  of  observations  must  be  made  on  the 
same  individual  before  deciding  whether  this  function  is  present.  We 
have  also  noticed  that  even  older  infants  do  not  shed  tears  witli  each 
crying-spell.  These  facts  are  at  times  quite  important  to  remember,  as  a 
suppression  of  the  lachrymal  secretion  occurs  where  the  infant's  vitality 
has  been  profoundly  affected  by  disease,  and  a  return  of  the  tears  is  an 
indication  for  giving  a  favorable  prognosis,  and  often  that  convalescence  is 
about  to  be  established. 

Sweat  Glands. — The  sweat  glands  are  developed  at  about  the  tliird  to 
the  fifth  week.  We  have  seen  an  infant  in  the  second  week  of  its  life  suf- 
fering so  much  as  to  have  its  circulation  seriously  interfered  with  from  the 
high  temperature  of  a  bath-room  wdiere  it  was  being  bathed,  while  the 
nurse  who  was  bathing  it  was  perspiring  profusely,  and  was  apparently 
perfectly  comfortable.  There  is,  however,  a  great  variation  in  the  time 
when  these  glands  develop,  and  at  times  even  in  the  second  week  of  life 
we  have  noticed  cases  where  the  head  was  seen  to  perspire  quite  freely.  In 
certain  individuals,  therefore,  the  function  of  the  sweat  glands  is  fairly 
developed  at  birth. 

Salivary  Glands. — ^The  saliva  is  a  secretion  which  is  somewhat  slow 
in  being  established,  both  in  quantity  and  in  its  amylolytic  property, 
There  is  not  much  flow  of  saliva  in  the  infant's  mouth  for  the  first  three 
or  four  months  of  its  life,  and  even  when  the  function  of  the  glands  has 
become  so  developed  that  the  saliva  appears  in  tlie  mouth  in  abundance, 
a  comparatively  small  amount  reaches  the  stomach  by  being  swallowed. 
It  flows  out  of  the  mouth  over  the  chin,  and  until  the  latter  part  of  the 
first  year,  when  its  amylolytic  action  has  become  established,  it  probably 
plays  but  an  insignificant  role  in  digestion.  The  salivary  secretion  contains 
a  certain  amount  of  ptyalin,  but  its  diastatic  powers  seem  to  be  in  process 
of  development,  and  this  should  indicate  to  us  that  this  function  ought  not 
to  be  forced  into  use  in  digestion  until  it  has  become  much  better  estab- 
lished, as  in  the  last  quarter  of  the  first  year. 

Pancreas. — The  amylolytic  action  of  the  pancreatic  secretion  is  but 
little,  if  at  all,  developed  at  birth.  In  the  last  three  or  four  months  of  the 
first  year  the  function  seems  to  have  become  fairly  well  established,  and 
to  a  degree  which  will  not  be  harmed  by  a  moderate  call  upon  it  for  the 
digestion  of  small  quantities  of  starch.  The  pancreatic  power  of  digesting 
fat  also  seems  to  be  slight  in  the  early  months  of  life,  but  to  increase 
gradually  and  to  be  well  established  by  the  end  of  the  first  year. 

Bile. — The  large  size  of  the  liver  at  birth  and  during  infancy  is  well 
adapted  to  the  great  metabolic  activity  whicli  is  needed  for  the  develop- 
ment of  this  period  of  life.  The  investigations  of  Jacubowitsch  and 
Baginski  show  that  the  bile  in  children  is  poor  in  inorganic  salts,  with  the 
exception  of  the  iron  salts.  It  is  also  distinguished  by  its  small  amount 
of  cholesterin,  lecithin,  and  fat,  and  the  smaller  percentage  of  its  glyco- 
cholic  and  laurocholic  acids,  ns   compared   with   lli«'   l)ile    of  laler   life. 


NORMAL    DEVELOPMENT. 


79 


The  bile  acids  have  the  property  of  arresting  pepsin  digestion,  and  thus 
the  small  amount  of  bile  acids  present  in  infancy  favor  the  action  of  the 
gastric  juice,  whose  feeble  ferment  would  otherwise  be  neutralized.  The 
incomplete  assimilation  in  infancy  of  very  fatty  food,  such  as  creamy  milk, 
15  due  to  this  lack  of  bile  acids,  for  the  latter  aids  in  the  emulsification  of 
fat  and  its  decomposition  into  fatty  acids  and  glycerine.  The  feeble 
aniiseptic  properties  of  the  bile  in  infancy  and  the  resulting  danger  of 
intense  fermentation  of  the  intestinal  contents  is  due  to  the  lack  of  bile 
acids. 

LYMPHATIC  SYSTEM.— The  high  development  of  the  lymphatic 
system  in  early  life  is  very  marked.  According  to  Foster,  not  only  are  the 
lymphatic  glands  largely  developed  and  more  active  than  in  the  adult  (as 
is  probably  shown  by  their  tendency  to  disease  in  youth),  but  the  quantity 
of  lymph  circulation  is  greater  than  in  later  years.  The  observations  of 
Kramstyk  show  that  particles  of  fat  are  xerj  easily  absorbed  in  early 
life.  Brunner's  and  Lieberkiihn's  glands  are  only  partially  developed 
in  early  life ;  the  solitary  and  agminate  follicles  are  rich  in  lymphoid 
tissue. 

THYROID. — The  thyroid  body  is  relatively  greater  in  the  infant  than 
in  the  adult. 

URINE. — The  function  of  the  kidney  begins  quite  early  in  fuetal  life, 
and  the  bladder  has  been  found  to  be  full  of  urine  at  birtli.  The  urine  is 
small  in  amount  at  birth,  and  during  the  first  twenty-four  hours  it  is  not 
uncommon  to  find  little  or  none  jDassed.  The  urine  which  is  first  passed 
is  usually  dark,  cloudy,  and  acid,  and  contains  epithelial  cells  and  urates 
and  occasionally  hyaline  casts  ;  later  it  becomes  clear,  pale,  straw-yellow, 
and  usually  of  slightly  acid  reaction.  Its  specific  gravity  (1.010  at  birth) 
falls  in  two  or  three  days  to  1.003,  by  about  the  fifteenth  day  is  found  to 
be  1.006,  and  rises  from  this  time  steadily  till  puberty.  By  the  end  of  the 
first  week  and  throughout  childhood  the  amount  of  urine  passed  m 
twenty-four  hours  is  relatively  greater  than  in  adult  life.  This  in  early 
infancy  may  be  due  to  the  preponderance  of  liquid  food,  but  is  in  part 
the  result  of  the  infant's  more  active  metabolism,  for  the  urea  is  also 
found  to  be  proportionately  increased.  According  to  Foster,  the  presence 
of  uric  and  oxalic  acid  in  unusual  quantities  is  a  frequent  characteristic  of 
the  urine  of  children.  It  is  also  stated  that  the  phosphates  are  deficient, 
being  retained  in  the  body  for  the  purpose  of  builchng  up  the  osseous 
system.  The  chlorides,  sulphates,  and  urinary  pigments  are  less  abundant 
than  in  the  adult.  The  proportion  of  salts  increases  as  soon  as  a  mixed 
diet  is  given  and  closely  approaches  to  the  normal  proportion  for 
adults.  Indican  is  normally  absent  in  breast-fed  infants ;  in  others  it  is 
usually  absent  unless  there  is  a  disturbance  of  digestion.  The  uric  acid 
infarction,  which  has  been  referred  to,  and  e\idences  of  which  may 
last  for  two  or  three  weeks,  consists  of  urate  of  ammonium  (hedgehog 
crystals),  amorphous  urates  mixed  with  urii-  acid  crystals,  and  some  epi- 


80 


PEDIATFilCS. 


thelial  cells  (Plate  III.,  facing  page  77).  The  vaiiations  in  the  amount 
of  urine  wliich  has  been  computed  to  be  passed  during  the  eariy  days  of 
infancy  and  cliildhood  are  very  great,  as  the  amount  in  all  probability 
depends  very  largely  on  the  quantity  of  liquid  ingested,  and  also  upon 
the  activity  of  the  skin  and  bowels.  It  is  well,  however,  to  have  some 
general  idea  of  the  normal  total  amount  of  the  uiine  at  different  ages  in 
order  to  understand  better  the  diseased  conditions  of  the  kidney. 

The  difticuUies  in  accurately  measuring  the  amount  of  mine  excreted 
by  very  young  infants  are  such  that  few  positive  statements  can  be  made 
as  to  the  quantity.  It  is  sufficient  to  say  that  it  is  about  ninety  cubic 
centimetres  (three  ounces)  a  day  for  the  hi'st  few  days,  and  then  rises  in 
amount  very  rapidly. 

Rietz  and  Cruse  state  that  dming  the  first  few  days  of  life  the  urine 
contains  more  or  less  albumin,  and  that  tliis  disappears  at  about  the 
seventh  or  eighth  day,  and  sometimes,  according  to  Carpenters  work,  it 
may  be  detached  for  several  weeks.  Lesne  and  Merklen  found  the  freez- 
ing point  at  birth  about  0°  C.  at  one  month  —0.13°  to  —():?>b°  C,  at  two 
months — 0.21=  to — 0.78 
that  is  passed  is  cloudy 
healthy  infants  during  the  first  two  months. 

The  following  figures,  compiled  m  part  by  Holt,  ai'e  the  averages 
obtained  by  combining  the  results  of  the  investigations  of  Schabanawa, 
Cruse.  Camera,  Pollak.  ^lartin-Pvuge.  Berti.  Schiff.  Herter.  Vierordt. 
Renault,  and  others  : 

TABLE  19. 


■-^^  C.    It  also  frequently  happens  that  the  first  urine 
Susrar  is   occasionallv  found   in  the  urine  of 


Days 


Daily 

Quantity  of 

Urine  in 

Health. 

0-60  C.C- 
10-90      ■'  . 


Specific 
Gravity. 


Ratio  of 

Uric  Acid 

to 

Urea. 


DaOy 
Quantity  of 
of  Urea  in 

Gm. 


..   1   1.010-1.012  .       ltol4 0.076-0.114 


Quantity  of 

Urea  t*er 

Kil.  of  Body 

Weight. 

0.02tB 


Xo.  of  C.C. 
of  Urine 

for  each 
Eol.ofBodv 

Weight. 


Months 


Years 


1.001-1.008 


1  to  60-80, 


I- 


0.0919 . 
0.23 . . . 


250-600 


i) 
V 

if 

9 
10 
U 
12 

13 

14 


.500-800 


600-1200' 


3.0  (?)... 


::::; 


0..5  (?)... 


::} 


13.09  to  14.01. 


•  1.012-1.0-30  . 


1  to  4-5-00  . 


1   Bov, 

;  Girl. 

Bov, 


1.017  1  Bovs.  .53.0:5 
0.961  /Girls,  48.00 
1.06  Bov,  78.00 
0.811  "  47.06 
0.61        


16.06  to  21.03. 


0.88 
'  0.606 


Adult 0.55 


75.64 
'23'.i2 
.2S".66 


NORMAL    DEVELOPMENT.  81 

The  urinary  sediment  of  the  young-  infant  shows  on  microscopical 
examination  mucus,  many  epithelial  cells,  crystals  of  uric  acid,  urates, 
and  calcium  oxalate  ;  also  amorphous  urates,  occasionally  a  few  hyaline 
casts,  and  rarely  a  granular  cast.  The  urine  of  later  infancy  and  child- 
hood has  no  microscopical  peculiarities. 

INTESTINAL  DISCHARGES.— The  contents  of  the  intestine  con- 
tinue to  be  mixed  with  meconium  for  three  or  four  days  or  a  week,  the 
longer  time  being  when  the  infant  is  weak  and  does  not  nurse  well.  After 
this  time  the  infantile  discharges,  which  have  a  characteristic  appearance 
as  distinguished  from  those  of  the  older  child,  appear.  It  is  necessary  to 
be  familiar  with  their  characteristics,  as  they  are  an  important  guide  to  the 
proper  feeding  of  the  infant  and  are  an  index  showing  whether  the  food 
is  properly  digested  and  assimilated.  When  the  nutriment  is  milk,  with 
the  percentages  of  its  different  elements  corresponding  to  what  is  normally 
found  in  good  average  human  milk,  the  discharges  are  of  a  golden  yellow 
color,  smooth,  unformed,  of  medium  consistency,  sho^dng  a  large  pro- 
portion of  water,  and  sometimes  changing  on  exposure  to  the  air  to  a 
greenish  yellow.  They  as  a  rule  contain  undecomposed  bile-pigment  and 
bile-salts,  while  the  older  child's  and  the  adult's  discharges  do  not  contain 
the  bile  undecomposed.  The  amount  of  IVecal  discliarge  in  the  first  day 
of  life  is  about  forty-five  grammes  (one  and  onc-lialf  ounces),  and  in- 
creases in  the  following  days  to  fifty  grannnes  (one  and  two-tliirds  ounces). 
It  consists  of  mucous,  fat,  epithelial  remains,  and  a  slight  amount  of  albu- 
minoid material.  In  early  hifancy  there  are  from  two  to  four  discharges 
daily.  As  the  child  grows  older  there  are  two  and  finally  one  in  the 
twenty-four  hours.  They  do  not  lose  their  yellow  color  until  amylaceous 
or  albuminous  food  is  given,  when  the  different  shades  of  brown  begin  to 
appear.  They  are  not  fully  formed  until  something  besides  milk  is  swal- 
lowed. Starting  at  birth  with  the  sterile  meconium,  infection  by  the  mouth 
and  rectum  quickly  occurs,  and  in  a  short  tujie  almost  any  form  of  bacteria 
may  be  found  in  the  discharges,  but  chiefly  such  p^itrefying  forms  as  pro- 
teus  vulgaris  (Jeffries).  With  the  suckling  of  the  infant  and  the  substitu- 
tion of  the  refuse  of  the  milk  and  the  secretion  of  the  digestive  tract  for 
the  meconium,  a  sharp  transition  occurs.  Instead  of  the  generally  dis- 
tributed forms,  causing  decomposition,  only  two  kinds  of  bacilh  are  now 
regularly  found,  the  bacillus  lactis  aerogenes  and  Brieger's  bacillus,  the 
first  chiefly  in  the  upper  parts  of  the  intestines,  the  second  in  the  lower 
part.  When  the  infant  begins  to  take  a  mixed  diet,  cjuite  a  number  of 
forms  of  bacilli  appear,  among  them  the  streptococcus  coli  gracilis,  the 
putrefying  green  fluorescing,  a  tetrad  coccus,  and  several  kinds  of  yeast. 
The  color  of  the  infantile  intestinal  discharges  when  the  nutriment  is  milk 
alone,  whether  human  or  animal,  seems  to  depend  somewhat  on  the  per- 
centage of  fat,  as  is  seen  in  Plate  III.,  facing  page  77,  where  the  color 
resulting  from  the  food  containing  different  percentages  of  fat  is  repre- 
sented in  Nos.  3,  4,  6,  7,  8,  and  9. 

6 


82  PEDIATRICS. 

INFANTILE  SKELETONS.— Fig.  26  represents  the  skeleton  of  an 
infant  at  term,  and  Fig.  27  that  of  an  infant  at  nineteen  months.  These 
skeletons  illustrate  some  of  the  differences  which  occur  in  the  bones 
during  their  process  of  development. 

In  the  younger  subject  the  head  is  large  in  proportion  to  the  small 
thorax,  and  there  is  a  lack  of  development  of  the  face  in  comparison  witli 
the  head,  which  is  very  evidently  due  to  the  rudimentary  development  of  the 
jaws.  The  anterior  fontanelle  is  widely  open.  On  examining  closely  the 
sternum  it  will  be  noticed  that  it  is  not  in  one  piece,  as  in  the  adult,  but 
that  the  centres  of  ossification  with  the  intervening  cartilaginous  connec- 
tions are  well  marked.  The  pelvis  is  tilted  forward,  as  compared  with 
the  adult's,  and  is  small  and  contracted.  The  legs  are  not  straight,  as  in 
the  older  child,  but  show  decided  bowing  of  the  tibia  and  fibula.  This 
characteristic  condition  of  the  legs  in  intra-uterine  life  is  present  at  birth 
and  continues  for  some  months,  the  bones  usually  becoming  straight  by 
the  time  that  the  period  of  walking  has  been  reached.  In  the  skeleton  of 
the  infant  nineteen  months  old,  the  legs  have  developed  naturally  in  their 
growth  and  are  straight.  The  pelvis  still  tilts  somewhat,  but  is  evidently 
less  contracted,  or  rather  has  begun  to  enlarge.  The  thorax  has  broad- 
ened in  comparison  with  the  head,  and  the  cartilaginous  sternum  has 
become  to  a  large  degree  bone.  The  head  is  still  large  proportionately  to 
the  face,  although  the  jaws  have  developed  considerably  beyond  what  is 
seen  at  birth.  The  anterior  fontanelle  is  cjuite  small  in  comparison  with 
the  fontanelle  of  the  new-born  infant.  These  are  the  chief  characteristics 
of  the  infant's  and  child's  skeleton. 

NORMALLY  DEVELOPED  INFANTS. — One  of  the  greatest  draw- 
backs to  the  proper  appreciation  of  the  kind  of  knowledge  which  is 
needed  to  examine  and  treat  children  successfully  and  intelligently  when 
they  are  sick,  is  the  lack  of  precise  facts  concerning  healthy  children. 
It  is  therefore  important  to  know  at  a  glance  whether  it  is  normal  for  a 
child  not  to  sit  alone  or  not  to  stand  alone,  and  to  understand  its  childish 
actions,  whether  in  creeping  or  in  walking. 

The  ages  at  which  infants  develop  so  as  to  gradually  become  chil- 
dren are  important  to  determine,  for  it  is  just  as  Avrong  to  task  by  prema- 
ture use  the  function  of  locomotion  as  that  of  digestion.  A  normal  infant 
should  hold  up  its  head  without  support  at  the  second  or  third  month ;  it 
should  sit  alone  at  from  seven  to  nine  months,  creep  at  about  ten  months, 
stand  at  about  twelve  months,  and  Avalk  at  about  fifteen  months. 

TOPOGRAPHICAL  ANATOMY  OF  THE  EARLY  PERIODS  OF 
LIFE. — It  is  important,  for  purposes  of  diagnosis,  to  recognize  the  fact 
that  the  organs  differ  in  the  space  which  they  occupy  in  the  body  accord- 
ing to  the  stage  of  development  of  the  child.  Well-marked  periods  are 
thus  shown  to  exist  by  physical  examination  as  well  as  by  anatomical  re- 
search, and  the  results  of  these  different  methods  of  investigation  are 
found  to  correspond.     AVe  have  always  found  that  a  careful  consideration 


Fig.  27. 


Fk;.  2n. 


Infant  at  term,  showing  large  head,  large  ante-  Iniaut  at  19  mouths,  showmg  large  head,  bmall 

rior  fontanelle,  small  thorax,  cartilaginous  ster-  anterior  fontaneUe,  ossification  of  sternum,  tilted 

num,  tilted  peh^is,  and  bow-legs.  pelvis,  and  straight  legs. 

Warren  Museum,  Harvard  University. 


A'ORMAL  DEVELOPMENT. 


83 


of  the  period  of  development  is  of  the  first  importance  when  beginning  to 
make  a  diagnosis  of  disease,  especially  of  the  heart  and  lungs.  The  large 
size  of  the  liver  in  infants  and  the  comparatively  greater  proportionate  size 
of  the  heart  to  the  luns  in  the  middle  years  of  childhood  are  striking  m- 


FiG.  28. 


Fig.  29. 


Normal  infant  seven  months  old. 

stances  of  the  truth  of  this  statement,  and  should  warn  us  that  more  than 
ordinary  care  should  be  employed  in  diagnosticating  a  pneumonia  of  the 
right  lower  lobe  behind  in  infancy,  or  an  enlarged  heart  in  childhood. 
Three  periods  of  growth  are  of  especial  significance  in  this  connection  :  1. 
A  period  corresponding  to  the  development  of  the  organs  in  the  first  year, 
especiahy  in  the  first  half  of  the  year.  2.  A  period  occurring  during  the 
fourth,  fifth,  sixth,  seventh,  and  perhaps  eighth  and  ninth  years.  3.  A 
period  embracing  the  later  years  of  childhood. 

Figs.  28  and  29  represent  the  first  period.  The  infant,  seven  months  old  and 
normally  developed,  has,  outlined  in  black,  the  principal  points  both  in  front  and  be- 
hind which  will  be  useful  to  remember  when  making  a  physical  examination  at 
this  age. 

In  Fig.  28  the  plain  dark  lines  have  followed  the  lower  margin  of  the  ribs  and 
the  outline  of  the  ensiforni  cartilage  and  manubrium.  To  the  left  of  the  lower  part 
uf  the  left  sternal  line  is  a  small  curved  line.  This  represents  the  superficial  dulness 
of  the  heart.     The  relative  or  deep  dulness  is  very  slight.      By  very  delicate  percussion 


84  PEDIATRICS. 

it  iiiiiy  be  shown  to  oxteiid  above  to  the  second  rib,  to  the  h^ft  about  1  cm.  (.V  inch) 
outside  the  niannuillary  line  and  to  the  right  about  I  cm.  (.\  inch)  l)eyond  tbe  rig-lit 
sternal  Itorder.  The  area  of  superficial  dulness  can  almost  ix-  covered  by  the  end  ot 
the  finger  used  for  percussion.  It  is  hounded  by  the  fourth  rib  or  third  interspaci! 
above,  and  is  just  williin  the  mammillary  line.  There  is  very  fair  resonance  under 
the  whole  lengtli  of  the  sternum.  The  interrupted  lines  represent  the  upper  and 
lower  borders  of  the  liver.  The  upper  line  begins  in  the  fifth  interspace  in  the  mam- 
millary line  ;  in  the  seventh  in  the  mid-axillary  line  and  in  the  nintli  ])ehind.  The 
lower  line  is  interesting  and  instructive  as  illustrating  the  large  size  of  the  liver  in 
early  infancy,  and  how  little  of  the  stomach,  which  is  here  represented  by  a  dotted 
line  between  the  edge  of  the  liver  and  the  left  border  of  the  ribs,  is  to  be  reached  by 
percussion.  The  stomach  is,  of  course,  in  this  infant,  empty.  When  full,  it  comes 
out  much  farther  under  the  edge  of  the  liver.  The  broad  black  line  just  above  the 
level  of  the  umbilicus  marks  the  transverse  colon,  Avhich  in  infancy  has  a  relatively 
low  position.  The  c*cum,  which  is  marked  by  a  black  circle,  stands  high  in  the 
abdomen,  near  the  anterior  superior  spine  of  the  ilium.  The  upper  piece  of  the 
sternum  is  also  outlined,  as  is  the  clavicle  and  first  rib.  Fig.  29  shows  the  same 
infant's  back  ;  the  lower  borders  of  the  thorax,  the  kidneys,  and  the  lower  borders  of 
the  lungs  are  outlined.  The  left  kidney  is  decidedly  higher  than  the  right  at  this  age. 
While  the  lower  border  of  the  lung  on  the  left  comes  down  as  far  as  the  tenth  rib,  the 
corresponding  border  of  the  right  lung,  owing  to  the  large  size  of  the  liver,  descends 
only  as  far  as  the  ninth  rib. 

He  was  six  years  old,  properly  developed  for  liis  age,  and  presented  certain 
points  of  interest  which  differ  from  the  infant  and  the  adult,  and  which  should  be 
carefully  taken  into  account  when  we  are  making  a  physical  examination  at  this  age.  . 
The  manubrium,  the  clavicles,  the  first  and  second  ribs,  the  ensiform  cartilage,  and  the 
lower  borders  of  the  thorax  are  marked  in  black.  The  area  of  superficial  cardiac  dul- 
ness is  far  greater  than  in  the  infant,  Figs.  28  and  29.  The  dulness  should,  so  far  as  the 
sternum  is  concerned,  be  determined  by  light  percussion  dii'ectly  over  the  sternum  from 
above  downward.  In  this  way  we  can  detect  the  change  in  the  percussion  note  over 
the  lower  part  of  the  sternum  better  than  by  percussing  from  the  lung  to  the  sternum, 
iiince  the  former  is  so  much  more  resonant  that  the  sounds  are  more  difficult  to  dis- 
tinguish and  are  often  misleading.  The  upper  resonant  part  of  the  sternum,  on  the 
other  hand,  presents  an  excellent  opportunity  for  comparison,  and  brings  out  the 
delicate  shades  of  sound  which  are  needed  in  getting  the  i-elative  dulness.  This 
.  relative  dulness,  however,  is  usually  pronounced  under  the  lower  part  of  the  ster- 
num in  this  period  of  development,  and  it  shades  off  into  the  absolute  or  superficial 
dulness  of  the  precordia.  Absolute  dulness  under  the  slernuin,  unless  depending  on 
.pathological  conditions,  is  rare  even  at  this  age,  when  it  is  also  rare  not  to  have  this 
physiological  relative  dulness.  In  this  period  the  superficial  dulness  of  the  heart 
extends  higher  in  the  left  parasternal  line  than  at  any  other  time  of  life.  The  lower 
border  of  the  third  rib  usually  marks  the  upper  border  of  the  superficial  dulness,  which 
extends  also  to  the  left  sternal  line  and  keeps  well  within  the  mammillary  line.  The 
relative  or  deep  dulness,  on  the  other  hand,  reaches  as  high  as  the  lower  border  of  the 
second  rib.  It  then  passes  to  the  right  under  the  upper  third  of  the  sternum,  descends 
obliquely  to  the  fourth  right  costal  cartilage,  and  then  keeps  slightly  to  the  right  of  the 
right  sternal  line.  To  the  left  it  extends  well  out  to  and  perhaps  a  little  over  the 
mammillary  hue.  This  is  a  far  different  result  of  percussion  from  that  which  is  found 
in  the  adult,  and  also  in  the  infant  represented  in  Fig.  28,  in  whom  there  is  no  dulness 
under  the  sternum  and  the  superficial. dulness  rises  only  as  high  as  the  fourth  costal 
cartilage  in  the  left  sternal  line.  The  deep  dulness  also  extends  only  as  far  as  the 
mammillary  line.  The  impulse  of  the  heart  is  usually  found  a  little  higher  in  infants 
and  in  young  children,  irrespective  of  these  periods,  tiiau  in  older  children  and  in 
adults,  and  is  usually  in  the  fourth  interspace. 


NORMAL  DEVELOPMENT.  ■  85 

A  much  smaller  space  is  occupied  at  this  age  hy  the  liver  than  in  infancy.  The 
liver  is  indicated  by  the  double  line,  which  rises  as  high  as  the  fifth  rib  in  the  mam- 
miliary  line,  and  to  the  attachment  of  the  sixth  or  seventh  right  costal  cartilage  to  the 
sternum.  The  dotted  line  of  the  stomach,  on  the  other  hand,  occupies  a  much  larger 
space  than  in  the  infant.  The  line  of  the  transverse  colon  stands  proportionately 
higher,  the  c*cum  rather  lower.  Fig.  31  shows  the  lower  border  of  the  right  lung 
still  to  be  a  trifle  higher  than  that  of  the  left,  and  to  come  to  about  the  upper  border 
of  the  tenth  rib,  while  on  the  left  side  it  extends  to  the  lower  border  of  the  same  rib. 
At  this  age  the  liver  has  diminished  in  size  relatively  to  such  an  extent  that  the  differ- 
ence of  the  position  of  the  lower  borders  of  the  lung  is  but  slight. 

Figs.  30  and  31  represent  a  child  in  the  second  period  of  its  growth. 
In  this  middle  period  of  childhood  the  heart  has  developed  more  rapidly 
proportionately  than  the  lungs,  and  its  area  of  superficial  dulness  takes 
up  more  space  in  the  anterior  portion  of  the  thorax. 


Fig.  30. 


Fig.  31. 


J 


N<inii;il  ucvolopment  al  six  y 


The  kidneys  are  about  on  a  level  on  both  sides.  The  first  and^welfth  dorsal 
vertebrse  are  also  indicated  as  landmarks.  The  child  is  passing  through  transitional 
stages  of  physical  development,  and  is  gradually  approaching  the  adult  type  of  per- 
fected growth. 


86 


PEDLVTRICS. 


Perfect  growth,  so  far  as  the  topograpliy  of  the  organs  is  concerned, 
is  reached  in  the  third  period  represented  in  the  last  years  of  childhood 
and  at  about  the  age  of  puberty.  The  organs  of  the  child  seem  at  this 
age,  although  they  have  not  yet  acquired  their  complete  growth,  to  present 
for  purposes  of  percussion  the  outlines  which  we  are  accustomed  to  see 
in  the  adult,  with  the  exception  possibly  of  the  position  of  the  csecum. 


Fig.  32. 


Fig.  33. 


Normal  development  at  twelve  years. 


Fig.  32  shows  a  normally  developed  boy,  twelve  years  of  age,  and  illustrates  re- 
markably well  the  relative  topographical  correspondence  of  later  childhood  and  adult 
life. 

As  in  the  boy  of  six  years,  the  manubrium,  clavicle,  first  and  second  ribs,  ensi- 
form  cartilage,  and  the  lower  borders  of  the  thorax  are  outlined  in  black.  The 
curved  line  passing  up  the  left  sternal  line  to  the  fourth  rib  and  keeping  within  the 
mammillary  line  marks  the  superficial  dulness  of  the  heart,  and  corresponds  to  the 
topography  of  the  adult's  heart.  The  relative  or  deep  dulness  is  the  same  as  in  the 
adult.  The  upper  line  of  the  liver  is  about  at  the  level  of  the  fifth  rib  in  the  mammil- 
lary hne,  and  does  not  extend  beneath  the  lower  border  of  the  ribs,  but  is  just  below 
the  tip  of  the  ensiform  cartilage.  The  dotted  line  represents  the  stomach.  The  spleen 
has  its  upper  border  at  the  ninth  rib,  and  its  lower  portion  comes  down  as  far  as  the. 


NORMAL   DEVELOPMENT.  g7 

lower  border  of  the  eleventh  rib.  The  caecum  is  marked  iu  the  upper  part  of  the  right 
groin.  The  transverse  colon  is  about  midway  between  the  stomach  and  the  umbilicus. 
Looking  at  this  same  boy  from  behind  (Fig.  33),  it  will  be  seen  that  the  kidneys  and 
the  lower  borders  of  the  lungs  are  in  about  the  same  relative  position  as  occurs  in  the 
adult.     We  have  also  indicated  the  first  and  twelfth  dorsal  vertebraj. 

These  representatives  of  the  normal  development  of  miportant  periods 
of  life  not  only  were  carefully  mapped  out  by  ourselves  by  percussion  and 
in  accordance  with  the  anatomical  knowledge  which  we  possess  on  this 
subject,  but  also  were  verified  by  Professor  Dwight,  who  examined  each 
child  carefully  and  satisfied  himself  that  our  marking  was  correct. 

NURSERY. — Before  undertaking  to  treat  the  various  diseases  of  early 
life,  it  is  of  great  importance  to  acquire  a  practical  knowledge  of  the  care 
of  the  infant  and  child  in  health.  It  is  essentially  in  the  nursery  that  we 
should  study  the  healthy  child,  as  the  nursery  is  its  home,  where  it  feels 
most  at  ease  and  behaves  in  the  most  natural  manner.  The  general 
hygiene  of  the  child  is  represented  in  its  nursery,  and  we  should  therefore 
by  our  knowledge  and  advice  so  direct  these  c|uestions  of  nursery  hygiene 
as  to  give  this  sensitive,  easily  impressionable  young  human  being  the  best 
opportunity  to  develop  into  a  healthy  and  vigorous  adult.  We  cannot,  of 
course,  in  every  case  procure  for  the  child  the  surroundings  which  are 
best  for  it,  but  we  can  at  least  impress  on  the  parent  what  these  surround- 
ings should  be,  and  how  important  they  are  for  the  general  health  of  the 
child.  The  nursery  should  be  high  from  the  ground  and  out  of  reach  of 
the  dampness  which  arises  towards  the  latter  part  of  the  day. 

Sun  and  Windows. — It  should  have  a  sunny  exposure  and  large  Avin- 
dows  high  enough  from  the  floor  to  avoid  having  the  younger  children 
continually  pressing  their  faces  against  the  glass  to'  look  out,  and  thus 
frequently  catching  cold  from  the  little  currents  of  air  which  penetrate 
most  window-casings.  The  mothers  often  overlook  this  simple  manner 
of  catching  cold,  and  wonder  how  their  children,  who  are  so  closely 
watched,  could  have  contracted  the  catarrhal  conditions  which  arise  in  this 
way. 

Papers  and  Carpets. — It  is  much  better  not  to  have  a  paper  on  the 
wails  or  a  carpet  on  the  floor.  Young  children  are  very  susceptible  to 
inhalation  poisons,  and  to  organisms  of  all  kinds.  Many  a  case  of  anaemia, 
nasopharyngeal  catarrh,  and  stomatitis  ulcerosa  has  apparently  arisen 
from  arsenic  in  the  paper.  Dust  also,  with  its  multitude  of  organisms, 
which  with  the  most  careful  sweeping  it  is  impossible  to  get  rid  of,  is  an- 
other source  of  irritation  to  the  respiratory  tract.  Even  small  amounts  of 
arsenic  in  the  contents  of  the  house  appear  to  affect  certain  children,  and 
the  paper  itself  is  a  receptacle  for  micro-organisms  which  are  difficult  to 
eradicate. 

Picture-Mouldings. — It  is  advisable  not  to  have  any  picture-mouldings 
on  the  walls,  as  they  are  a  place  for  dirt  to  gather  which  it  is  impossible 
to  remove  properly. 


90  PEDIATRICS. 

vent  the  sparks  from  flying  out  on  the  rhild.  the  other  to  prevent  the  diild 
from  falling  into  the  fire.  Serious  accidents  have  happened  from  a  lack 
of  proper  precaution  regarding  this  apparently  self-evident  necessity.  The 
hot  air  from  the  fire  radiates  in  all  directions  into  the  room. 

Scales. — Properly  adjusted  scales  are  an  im]3ortant  part  of  the  nursery 
equipment.  The  scales  which  are  usually  provided  are,  as  a  rule,  very 
inadequate  for  the  minute  and  daily  weighing,  the  results  of  which  are  at 
times  of  such  great  assistance  to  the  physician  in  the  management  of  the 
infant's  food.  Never  hang  an  infant  in  anytliing  on  a  hook  to  weigh  it. 
Such  weights  are  usually,  from  the  continual  kicking  of  the  infant,  quite 
incoiTect.  Do  not  tliink  that  the  kitchen  grocery  scale  is  good  enough  for 
the  infant.  We  can  afford  to  have  incorrect  and  approximate  grocery 
weights,  but  cannot  afford  to  apply  these  methods  to  the  gro^^•ing  infant, 
with  its  unstable  equilibrium.  The  scales  should  be  of  a  smaU  but  solid 
platform  variety,  which  can  be  placed  on  a  firm  table  by  the  tub  where 
the  infant  is  to  be  bathed,  for  use  before  the  bath. 

The  scales  should  weigh  as  low  as  four  or  five  grammes  (one  drachm). 
A  basket,  with  a  small  soft  blanket  lining  it.  is  placed  on  the  platform  of 
the  scale,  and  the  naked  infant  is  weighed  in  the  basket.  The  scale  is 
balanced,  and  the  infant  immediately  taken  out  of  the  basket  without 
stopping  to  read  the  weight,  so  as  not  to  expose  it  too  long  while  uncov- 
ered. When  the  infant  has  been  dressed  the  scale  can  be  read,  and  the 
balance-weight  minus  the  weight  of  the  basket  and  blanket  (wliich  can, 
of  course,  always  be  a  constant  quantity)  gives  us  the  exact  weight. 
Weighing  with  the  clothes  on  is  a  very  unsatisfactory  procedure. 

BATHING. — The  question  of  the  bath  is  of  a  good  deal  of  importance 
in  the  early  months  of  life.  Unless  there  is  some  definite  contra-indica- 
tion.  an  infant  should  be  bathed  every  morning.  The  contra-indications 
are  if  the  skin  or  nails  turn  blue,  or  if  the  infant  seems  in  any  way  to 
show  symptoms  of  weakness  or  lowered  vitality  after  bathing,  such  as  are 
^  represented  by  cold  extremities  and  nose,  or  an  unusually  quickened  res- 
piration. In  these  cases  sponging,  merely  sufficient  for  cleanliness,  is  to 
be  substituted  for  the  bath.  The  bathing  should  be  done  ^^ith  celerity, 
the  tub  being  placed  on  the  side  of  the  fireplace  opposite  from  the  win- 
dow, and  fronting  the  latter,  so  as  to  avoid  draughts,  and  insure  a  good 
light.  The  nurse  should  sit  ^^-ith  her  face  to  the  light  and  have  the  m- 
fant  on  her  lap.  wrapped  up  in  a  warm  blanket,  ^^-ith  its  feet  towards  the 
fireplace,  and  its  head  in  such  a  position  as  regards  the  ^^indow  as  to 
avoid  ha^-ing  too  much  light  m  its  eyes.  There  should  be  a  rack  for  the 
towels,  wliich  should  be  kept  Avarm  in  front  of  the  fire  while  the  infant 
is  being  bathed.  The  clothes  should  in  like  manner  be  neatly  spread 
out  on  another  rack,  ready  to  be  put  on  as  soon  as  the  infant  has  been 
dried. 

Temperature  of   Bath. — The  water  should  vary  m  its  temperature 
somewhat  with  the  aa^e  of  the  infant,  but  should  never  be  so  cold  as  to 


NORMAL   DEVELOPMENT.  92 

cause  blueness  or  cold  extremities.  We  must  also  be  careful  not  to  have 
the  water  too  hot,  as  this  has  sometimes  proved  to  be  injurious.  Each 
infant,  however,  must  have  the  temperature  of  its  bath  adapted  to  its  own 
vitality.  A  convenient  bath  thermometer  is  one  which  is  guarded  from 
breaking  by  a  wooden  frame,  which  also  allows  it  to  float  in  the  water, 
and  the  nurse  is  thus  enabled  to  see  at  a  glance  that  the  bath-water  is 
remaining  at  the  proper  temperature.  The  following  table  may  be  taken 
as  a  guide  : 

TABLE  20. 

Temperature  of  the  Bath  for  Different  Ages. 

Age.  Centigrade.    Fahrenheit. 

At  birth 36.6°  98° 

During  first  three  or  four  weeks 3-5°  95° 

One  to  six  months 34°  93.2° 

From  six  to  twelve  months 32.2°  90° 

Twelve  to  twenty-four  months 30°  86° 

Then  gradually  reduce  in  summer  to 26.6°  80° 

In  the  third  or  fourth  year,  if  possible,  reduce  to 23.8°  75° 


The  nurse  should  first  wash  the  face  in  clear  Avater,  keeping  the  body 
and  limbs  wrapped  up  in  a  warm  blanket.  The  face  is  then  wiped  with  a 
soft  towel.  She  should  gently  cleanse  the  nose,  the  corners  of  the  eyes, 
and  the  external  ears.  The  nose  is  especially  important,  for  the  infant's 
vitality  is  easily  affected  by  occluded  nares.  The  nurse  should  then  soap, 
wash  off,  and  dry  the  scalp.  The  sponge  and  water  in  the  other  division 
of  the  bathing  basin  are  then  used  for  soaping  the  body  and  extremities. 
Especial  care  should  be  paid  to  the  folds  of  the  neck,  the  axilla?,  groins, 
genitals,  and  anus.  The  temperature  of  the  water  in  the  basin  and  batli 
should  be  taken  from  time  to  time  with  the  wooden  bath  thermometer 
until  the  washing  is  over.  The  proper  warmth  of  the  Avater  is  to  be 
kept  by  adding  when  necessary  a  little  hot  or  cold  water  from  cans 
within  easy  reach. 

Tub. — ^The  tub,  Avhich  is  preferably  made  of  rubber  hung  on  a  simple 
wooden  frame  and  sufficiently  high  to  prevent  needless  stooping  on  the 
part  of  the  nurse,  is  placed  on  the  nurse's  left,  at  a  convenient  distance 
from  her  chair. 

Basin. — In  front  of  the  nurse  is  the  double  Avashing  basin,  Avhich  is 
merely  a  china  basin  divided  into  tAvo  compartments,  and  fitted  to  a 
wicker  stand,  also  sufficiently  high  to  prevent  the  nurse  from  stooping  as 
she  uses  it.  To  the  right  of  the  nurse  is  the  table,  Avith  the  scales  on  one 
end  and  the  toilet  basket  on  the  end  toAA^ards  her. 

Soap. — The  soap  should  be  Avhite  castile,  or  any  kind  Aviiich  is  free 
from  irritating  elements. 

Sponges. — There  should  be  tAvo  sponges  :  one  goes  in  one  side  of  the 
washing  basin,  and  is  for  the  head  and  face  ;  the  other  is  to  be  used  in  the 
opposite  side  of  the  basin,  and  is  for  the  body  and  extremities.    The  body 


92  PEDIATRIC'S. 

and  limbs  having  been  tlioroughly  and-  quickly  soaped,  the  nurse  should 
gently  lower  the  infant  with  its  face  up  into  the  clear  water  in  the  bath, 
being  careful  not  to  frighten  it  or  to  drop  it.  This  is  not  an  unnecessary 
warning.  We  have  known  infants,  even  in  the  hands  of  ordinarily  careful 
mothers,  to  be  dropped  from  the  bath  or  scales,  with  a  resulting  })erma- 
nent  injury  of  the  spine  or  hip.  After  allowing  the  infant  to  kick  and 
splash  for  a  few  seconds,  it  is  taken  back  into  the  nurse's  lap  and  care- 
fully dried  with  a  warm,  soft  towel.  Never  soap  and  wash  the  infant  in 
the  bath,  but  always  on  the  lap. 

Powder. — When  the  skin  is  perfectly  soft,  clear,  and  in  a  normal  con- 
dition, no  powder  is  needed.  Where  there  is  any  slight  irritation,  Avhich, 
at  times,  is  liable  to  occur  when  the  skin  has  not  been  kept  sufficiently  dry, 
especially  if  there  is  a  decided  redness  in  the  folds  of  the  skin,  as  of  the 
neck,  axillae,  or  groins,  the  following  powder  can  be  applied : 

Prescription  1. 
Metric.  Apothecary. 

Gramma. 


R      Pulv.  zinci  oxidi 7 

Pulv.  amvli  trit GO 


5  R     Pulv.  zinci  oxidi g  ii ; 

0  Pulv.  amvli  trit 5  ii. 


M.  M. 

No  perfume  of  any  kind  should  be  added  to  the  powder.  The  infant 
should  be  sweet  and  pure  in  itself,  without  accessory  odors. 

CLOTHING. — It  is  very  important  that  those  who  care  for  the  infant 
should  not  only  clothe  it  properly  but  should  understand  why  one  method 
of  clothing  is  better  than  another.  The  surface  of  the  infant's  body  is 
greater  in  proportion  to  its  entire  weight  than  is  the  case  in  the  older  and 
hence  larger  human  being.  Greater  surface  means  that  there  is  a  greater 
opportunity  for  radiation,  and  hence  that  the  smaller  subject  will  cool  off 
more  quickly,  other  conditions  being  equal,  than  the  larger  one.  We 
therefore  see  at  once  that  much  care  should  be  given  to  the  question  of 
warmth  in  the  infant.  Any  exposure  of  the  body  or  limbs  in  either  in- 
fants or  children  is  unwise.  A  very  important  factor  in  the  problem  of 
growth  in  the  infant  is  perfect  freedom  of  motion  for  its  legs  and  arms  and 
for  the  respiratory  and  abdominal  muscles.  It  should  also  be  thoroughly 
understood  that  pressure  on  any  portion  of  the  body  or  limbs  must  pro- 
duce evil  results,  by  displacing  organs  which  should  be  allowed  to  have 
entire  freedom  of  position  in  their  respective  cavities. 

Too  little  warmth  will  do  harm,  by  preventing  the  proper  metabolism 
of  the  tissues  and  thus  reducing  the  animal  heat.  Too  great  warmth,  on 
the  other  hand,  by  causing  inequalities  in  the  circulation,  will  in  like  man- 
ner be  detrimental  to  the  child's  growth  and  vigor.  Clothes  which  bind 
any  part  of  the  infant  tightly  cannot  but  press  out  of  their  natural  position 
whatever  happens  to  be  beneath  the  point  of  pressure,  whether  it  be  the 
liver,  the  intestines,  or  the  toes.  The  clothes,  then,  must  evidently  be 
xvarm  and  loose,  and  we  must  bear  in  mind  that  loose  clothes  are  warmer 


NORMAL   DEVELOPMENT.  93 

than  tight  ones,  from  the  very  fact  that  they  do  not  interfere  ^vith  the 
natural  activity  of  the  circulation,  and  that  they  give  freer  play  to  all  the 
muscles  which  produce  the  noriaal  warmth  arising  from  exercise.  We 
must  remember  that  the  only  way  in  which  the  infant  can  obtain  the 
exercise  so  much  needed  for  proper  growth,  and  which  is  so  easily  ob- 
tained by  the  older  child  in  running  about,  is  by  continually  moving  its 
legs  and  arms  and  thus  accelerating  the  muscular  action  of  its  thorax  and 
abdomen. 

An  important  item  in  the  proper  management  of  the  infant  in  its  nur- 
sery is  that  it  should  be  irritated  as  little  as  posssible  by  unnecessary  delay 
in  dressing  it  after  its  bath.  Useless  stitches,  buttons,  and  articles  of 
clothing  should  be  dispensed  with,  and  a  method  adopted  which,  while 
combining  the  necessities  of  dress,  will  allow  the  dressing  to  be  finished 
before  it  has  time  to  annoy  the  infant. 

Abdominal  Band. — There  is  no  necessity  for  using  beyond  the  first  two 
or  three  weeks  the  usual  flannel  band  supposed  to  be  so  indispensable 
by  the  average  nurse.  Hernise,  whether  umbilical  or  inguinal,  cannot  be 
obviated,  and  in  fact  may  be  produced,  by  undue  abdominal  pressure. 

The  abdominal  band  shown  in  Fig.  35  A,  made  of  light,  soft  flannel, 
can  be  smoothly  applied  over  the  dressing  of  the  cord  and  kept  in  place 
with  moderate  pressure  by  means  of  safety-pins. 

The  band  can  soon  be  replaced  by  a  somewhat  elastic  knitted  garment 
(Fig.  35  E,  a),  half  band  and  half  shirt,  with  shoulder-straps  of  the  same 
material  to  hold  it  in  place,  and  a  tab  in  front  to  fasten  it  with  a  safety-pin 
to  the  napkin  (Fig.  35  E,  b). 

This  shirt  can  be  made  of  soft  wool  or  silk,  or,  as  Ave  have  recently 
found,  can  be  knitted  in  any  form  or  size  from  half  cotton  and  half  silk. 

This  knit  material  can  also  be  used  for  the  undershirts  (Fig.  35  B  and 
Fig.  36  F,  pages  95  and  97).  Garments  made  in  this  way  are  the  best 
that  we  have  ever  seen.  They  are  warm,  soft,  and  delicate,  have  no  seams, 
can  be  washed  without  shrinking,  and  retain  their  elasticity  much  better 
than  those  made  from  other  materials. 

Napkins. — The  napkin  (Fig.  35  E,  b,  page  95)  is  folded  and  fastened 
with  safety-pins  as  is  customary  for  keeping  it  in  place.  The  usual  nap- 
kin is  very  cumbersome  and  heavy,  besides  being  expensive.  It  can  be 
replaced  by  rolls  of  soft  absorbent  gauze,  wliich  absorb  the  urine  from  the 
skin,  an  important  quality  in  cases  where  the  skin  is  easily  irritated.  These 
napkins  can  simply  be  cut  from  the  roll,  wliich  is  kept  in  the  nursery,  and, 
when  removed  from  the  infant  after  a  movement  of  the  bowels,  can  be 
burned,  thus  avoiding  the  trials  resulting  from  the  objections  of  the  nurse 
or  the  laundress  to  washing  the  napkins.  If,  however,  the  mother  prefers 
the  regular  old-fashioned  napkin,  small  squares  of  this  gauze  can  be 
placed  in  the  middle  of  the  napkin,  and  this  will  in  great  measure  obviate 
the  more  disagreeable  part  of  the  napkin-washing,  as  the  square  of  gauze 
^vill  hold  most  of  the  movement  and  can  at  once  be  liurnod. 


94  PEDIATRICS. 

Tlie  infant  while  in  long  clothes  need  not  have  any  further  covering 
for  its  legs,  and  need  have  nothing  on  its  feet.  There  is  no  particular 
objection  to  little  knit  socks  if  the  mother  wishes  to  use  them. 

After  the  nurse  has  put  on  the  band  and  the  napkin  there  are  left 
three  garments  which  are  usually  the  clothes  needed  to  complete  the 
infant's  outfit  of  long  clothes. 

These  garments  are  the  shirt  (Fig.  35  B,  page  95),  the  petticoat  (Fig. 
35  C),  and  the  dress  (Fig.  35  D). 

SHmx  (Fig.  35  B). — The  shirt  is  a  garment  with  long  sleeves  and  liigh 
neck,  cut  almost  as  long  as  the  outside  white  slip  or  dress.  Unless  it  is 
knitted  it  is  well  to  have  it  made  of  some  soft,  fine,  all-wool  material, 
with  the  seams  finished  on  the  outside  to  prevent  irritation  of  the  skin. 
It  is  made  to  button  in  the  back.  A  fresh  garment  of  this  kind  is  also  suf- 
ficient for  the  infant's  dress  at  night,  except  during  the  early  Aveeks  of  life. 

Petticoat  (Fig.  35  C). — A  flannel  shirt  cut  all  in  one  piece,  as  the 
shirt  is  made  of  fine  flannel,  with  no  sleeves  and  with  low  neck,  repre- 
sents the  petticoat.  It  should  be  made  large  enough  to  go  over  the  shirt, 
should  be  of  the  same  length  as  the  dress,  and  should  also  be  made  to 
button  in  the  back.  The  taste  of  the  mother  can  be  gratified  by  any 
reasonable  degree  of  emlDroidery  which  she  may  wish  to  put  on  this 
second  garment,  but  the  shirt  should  be  perfectly  plain. 

Dress  (Fig.  35  D). — The  outer  garment  should  be  made  of  some  soft 
white  material,  such  as  nainsook,  should  be  large  enough  to  go  over  the 
sliu"t  and  petticoat,  should  not  be  starched,  and  is  usually  about  one  yard 
long  from  the  neck  to  the  bottom  of  the  skirt.  It  should  have  high  neck 
and  long  sleeves,  and  should  button  behind. 

The  advantage  of  this  costume  is  that  it  is  loose  but  Avarm.  and  that 
the  three  pieces  wtiich  constitute  it  can  be  put  on  together,  the  infant 
having  to  be  turned  over  only  once  before  the  clothes  are  buttoned.  The 
sother  methods  of  clothing  usually  necessitate  turning  the  baby  over  sev- 
eral times  in  the  process  of  dressing. 

Before  the  infant  has  had  its  bath,  these  three  articles  of  dress  are  to 
be  arranged  one  inside  the  other,  ready  to  be  slipped  on  all  three  at  once. 
This  can  be  done  with  great  celerity,  and  the  dressing  process  can  thus  be 
gone  through  without  the  usual  accompaniment  of  irritated  cries  which 
are  so  frequently  heard  in  the  nursery,  and  which  are  to  be  deprecated. 

When  the  infant  is  old  enough  to  have  its  long  clothes  changed  to  short 
ones,  wliicli  is  at  about  the  time  when  it  learns  to  creep,  the  under-gar- 
ment  can  be  replaced  by  a  knitted  or  fine  all-woxd  undershirt  with  high 
neck  and  long  sleeves  (Fig.  36  F,  page  97)  made  short,  with  an  additional 
white  petticoat  in  winter  if  desired.  The  infant  should  noAv  also  have  its 
feet  and  legs  covered  with  long  white  avooI  stockings,  which  are  kept  ia 
position  by  being  pinned  to  the  napkin  (Fig.  35  E,  b,  page-95).  When  the 
child  begins  to  walk,  soft  kid  shoes  should  be  used  with  the  soles  adapted 
to  the  natural  curves  of  its  feet,  as  explained  on  pages  98  and  99. 


NORMAL   DEVELOPMENT. 


95 


■^ 


Fig.  35. 
(Long  Clothes.) 

A 

;:3r— 


fa  A  - 


■'^iiiSi'^iih^^ 


Flannel  band  for  earlv  weeks 


Dress. 


A.  knit  band  ;  B,  napkin  :  C,  stocking. 


96  PEDIATRICS. 

Stockings. — A  word  in  regard  to  the  stockings  is  especially  needed  in 
reference  to  the  older  child  in  its  third,  fourth,  and  fifth  years.  It  is  a 
mistake  to  think  that  if  we  keep  the  feet  and  abdomen  warm  the  legs  can 
be  left  uncovered  with  impunity.  Short  stockings  and  bare  legs,  in  our 
opinion,  should  be  abolished,  as  a  prolific  source  of  catarrhal  conditions. 
The  argument  is  a  poor  one  that  certain  children  have  been  known  to 
grow  up  well  and  strong  with  uncovered  legs,  or  even  that  our  ancestors 
were  in  the  habit  of  depriving  their  children  of  suitable  coverings  for  their 
necks  and  arms  as  well  as  legs,  while  they  themselves  were  warmly 
clothed  from  head  to  foot.  Our  ancestors  did  and  said  many  things  which, 
to  us,  convict  them  of  great  ignorance.  The  stockings  should  be  white. 
This  is  to  insure  freedom  from  poisonous  dyes,  which  at  times  seriously 
affect  the  delicate  skin  of  the  young  child.  Colored  stockings  are  a  source 
of  great  gratification  to  lazy  nurses  and  to  those  who  wish  to  lessen  the 
size  of  their  laundry. 

There  are  three  garments  which  are  usually  put  over  the  shirt  and  are 
considered  to  complete  the  short  clothes.  These  are  the  flannel  petticoat, 
the  white  petticoat,  and  the  dress,  and  they  are  to  be  made  large  enough 
to  fit  over  the  other  and  thus  to  be  put  on  all  at  once. 

Flannel-Petticoat  (Fig.  36  G,  page  97). — The  inner  garment  next  to 
the  shirt  has  a  flannel  skirt,  a  cotton  waist,  low  neck,  no  sleeves,  and  is 
fastened  with  buttons  in  the  back. 

White-Petticoat  (Fig.  36  H,  page  97). — Next  to  the  flannel  petticoat 
comes  a  garment  with  a  skirt  of  some  soft  white  material,  with  a  cotton 
waist,  low  neck,  no  sleeves,  and  also  buttoned  in  the  back. 

Dress  (Fig.  36  I,  page  97).— Finally,  over  all  the  other  garments 
comes  the  dress,  which  is  made  with  high  neck  and  long  sleeves,  and  is 
buttoned  behind. 

Night-Dress  (Fig.  36  J,  page  98).— A  regular  night-dress  can  now  be 
used,  made  of  soft  flannel,  with  high  neck  and  long  sleeves,  and  buttoned 
""  behind.     An  extra  garment  can  in  cold  weather  be  worn  under  the  night- 
dress if  deemed  advisable  for  the  especial  child. 

FEET. — In  young  children,  although  the  foot  may  be  a\  ell  formed,  it 
is  very  weak,  so  that  the  arch  is  easily  broken  down.  The  pad  of  fat,  to 
which  reference  has  been  made  under  development,  is  a  physiological 
protection  against  such  breaking  down.  Children  should  not  be  allowed 
to  walk  until  some  time  after  they  are  ready  to  do  so,  always  allowing, 
of  course,  that  if  they  insist  on  walking  they  can  seldom  be  restrained 
from  doing  so.  As  they  get  older,  long  walks  Avith  their  parents  should 
be  forbidden,  for  it  is  through  these  long  walks  that  the  evils  which  have 
been  explained  are  brought  about.  The  child  will  get  exercise  enough 
at  its  play,  and  in  doing  so  will  not  overtax  the  arch  of  the  foot,  or  use 
its  feet  beyond  the  degree  which  nature  intended.  Children  should  not 
be  told  to  turn  the  toes  out  too  much,  as  this  puts  the  arch  in  a  position 
where  the  muscles  give  il   least  support.      The   average  dancing-school 


NORMAL   DEVELOPMENT. 


97 


Fig.  36. 
{Short  Clothes.) 

F 


Shirt. 


riaunel  petticoat. 


White  petticoat. 


98 


rEDIATRICS. 


master  is  a  fair  example  of  what  over-zealous  ignorance  combined  with 
the  respected  traditions  of  the  past  can  do  to  children's  feet. 

SHOES. — Children's  shoes  should  be  rights  and  lefts,  like  those  of 
adults,  as  the  present  style  of  straight  shoes  gives  no  support  to  the  arch 
during  a  very  important  period  of  its  growth  ;  this,  moreover,  also  tends 
to  push  the  great  toe  towards  the  median  line  of  the  foot,  so  as  to  cause 


Xight-dress. 


enfeebling  of  the  muscles  which  have  so  much  to  do  with  the  proper 
elasticity  of  the  feet. 

We  should,  therefore,  have  shoes  properly  adapted  to  the  child's  foot, 
— shoes  that  will  at  once  be  comfortable  and  leave  the  feet  free  to  develop 
and  fulfil  all  their  functions.  The  cliildren's  shoes  as  we  find  them  in  the 
stores  have  the  two  sides  of  each  slioe  symmetrical  and  ec|uidistant  from 
the  middle  line :  the  right  and  left  are  told  only  from  the  arrangement  of 
the  buttons,  and  are  frecfuently  worn  interchangealDly.  Xow,  the  foot  has 
no  such  median  line  on  each  side  of  which  the  parts  are  equally  disposed  ; 
and  its  two  edges  are  very  different,  as  a  glance  at  the  soles  of  a  one-and- 
a-half-year-old  child's  feet  shows  (Fig.  37). 

It  is  well  to  note  especially  that  the  phalanges  of  the  great  toe  do  not 
naturally  point  towards  the  outer  border  of  the  foot :  such  a  position, 
common  as  it  is  in  the  adult,  must  be  considered  as  an  acquired  deformity 
which  stai-ted.  in  all  probability,  ^^^th  the  first  pair  of  leather  boots. 


NORMAL    DEVELOPMENT. 


99 


That  this  matter  of  forcing  the  first  toe  out  of  its  normal  position  may 
bring  with  it  very  serious  consequences  is  easily  shown  ;  as  it  inclines 
against  the  terminal  phalanx  of  the  second  toe,  it  often  crowds  it  back- 
ward, and  finally  makes  it  the  distressing  "  hammer  toe,"  which  may  even 
require  a  surgical  operation  for  its  relief.  On  the  inside  of  the  foot,  as 
soon  as  the  axis  of  the  first  toe  is  bent,  we  begin  to  find  a  bulging  out  of 


Fig.  87. 
(Natural  size,  1^  years.) 


Unsuitable  shape  for  sole  of  child's  shoe. 


\N ^y 

Suitable  shape  for  sole  of  child's  shoe. 


the  metatarsophalangeal  joint,  which  in  later  years,  fostered  by  pair  after 
pair  of  tight  and  ill-fitting  boots,  is  capable  of  giving  the  most  exquisite 
pain.  Still  more  subtle  in  its  working  than  this  is  the  trouble  that  often 
comes  from  disabling  the  great  toe  from  performing  its  full  function.  The 
elasticity  of  one's  step  depends  largely  upon  one's  power  to  press  down 
firmly  with  the  great  toe  and  then  raise  the  weight  of  the  body  over  it  as  a 
support.;  when  this  is  lost  by  crippling  the  toe  with  ill-shaped  boots,  the 
muscles  not  only  of  the  first  digit  but  of  many  adjacent  groups  begin  to 


100  PEDIATRICS. 

atrophy.  This  soon  leaves  the  internal  arch  of  the  foot  without  sufficient 
support,  and  the  long  series  of  woes  incident  to  "  flat-foot "  is  started  upon. 
Therefore,  for  one  and  all  of  these  reasons,  let  us  demand  that  children's 
feet  shall  have  at  least  the  chance  to  develop  properly  in  well-fitting 
anatomical  shoes, 

SLEEP. — Infants  and  young  children  vary  much  as  to  the  amount  of 
sleep  which  they  need  and  take  during  the  day.  At  first  they  sleep 
almost  continuously,  especially  if  they  happen  to  be  somewhat  premature. 
In  a  few  weeks,  how^ever,  they  begin  to  have  regular  periods  of  rest,  con- 
sisting of  several  hours'  sleep,  at  first  twice  in  the  day,  and  later  once. 
The  more  sleep  they  can  be  induced  to  take  in  the  twenty-four  hours,  the 
better.  As  they  grow  older  the  amount  of  sleep  which  they  take  grows 
less,  but  in  the  first  four  or  five  years  of  life  it  is  well  to  try  to  induce  the 
child  to  rest  quietly  on  its  bed  for  at  least  an  hour  during  the  day.  The 
number  of  hours  that  an  infant  or  child  sleeps  varies  so  with  the  indi- 
vidual that  precise  rules  cannot  practically  be  given  ;  one  simple  rule  holds 
true, — allow  each  child  to  sleep  as  long  as  it  naturally  can, 

WHEN  TO  GO  OUT  OP  THE  HOUSE.— If  the  infant  happens 
to  be  born  in  the  winter  months  and  the  weather  is  at  all  severe,  it  is  better 
to  keep  it  in  a  well-ventilated  nursery  than  to  run  the  risk  of  its  vitality 
being  lowered  by  exposure  to  cold.  We  believe  that  infants  in  our  northern 
climate  are  exposed  to  cold  far  more  than  they  ought  to  be,  and  that  they 
need  fresh,  warm,  dry  air,  rather  than  the  cold  and  often  damp  air  of  our 
winter  months.  When  they  are  born  in  a  milder  climate,  or  at  a  warmer 
season  of  the  year,  they  can  after  the  first  few  w'eeks  be  taken  out  in  their 
carriages  often  twice  a  day.  When  the  infant  is  five  or  six  months  old  we 
are  in  the  habit  of  giving  the  following  directions  to  the  mother  as  to  when 
she  shall  send  it  out.  We  explain  to  her  that  it  makes  as  much  difference 
whether  the  air  is  damp  or  dry,  and  w-hat  the  rate  of  the  wind  may  happen 
to  be,  as  does  the  number  of  degrees  indicated  on  the  thermometer.  If 
/-^he  sun  is  shining,  the  air  dry,  and  there  is  no  wind,  the  infant  can  with- 
out harm  go  out  for  an  hour  in  the  middle  of  the  day  even  at  a  tempera- 
ture of —6.6°  to  — 3.8'^  C.  (20°  to  25°  F,).  Where,  on  the  contrary,  the 
air  is  damp,  or  the  rate  of  the  wind  is  great,  it  is  better  for  the  infant  to 
remain  in  its  nursery,  and,  at  any  rate,  not  to  go  out,  if  the  temperature  is 
below  0°  C.  (32°  F.).  The  practice  of  allowdng  the  infant  to  sleep  in  the 
open  air  in  its  carriage  in  every  kind  of  weather  is,  we  believe,  a  bad  one  ; 
but  on  the  days  when  it  is  proper  for  it  to  go  out,  such  as  we  have  already 
described,  it  can  without  harm  sleep  in  the  open  air.  The  nurse  should 
be  directed  to  protect  the  infant's  eyes  from  the  direct  rays  of  the  sun,  and 
not  to  allows  a  strong  wdnd  to  blow  in  its  face. 

Where  the  weather  has  been  too  severe  or  damp  for  the  infant  to  go 
out  in  its  carriage  for  some  time,  it  is  advisable  to  have  it  dressed  warmly 
and  wheeled  up  and  dow^n  in  its  nursery  with  the  window  open  for  fifteen 
or  twenty  minutes.     To  avoid  too  much  draught,  blankets  can  be  placed 


XORM\L    DEVELOPMENT.  101 

over  the  cracks  of  the  doors  and  the  open  fireplace  while  the  infant  is 
breathing  the  fresh  air.  The  room  being  far  above  the  ground,  the  damp- 
ness is  avoided,  and  even  a  considerable  velocity  of  the  wind  outside  the 
house  will  in  this  way  be  unable  to  affect  the  air  of  the  room,  and  will 
not  make  too  strong  a  draught.  Where  it  is  possible,  as  is  the  casein 
certain  families  who  can  afford  such  a  luxury  for  their  child,  a  solarium  at 
the  top  of  the  house,  especially  in  cities,  is  desirable  and  practicable.  Not 
only  should  an  injudicious  administration  of  cold  air  be  avoided,  but 
extreme  care  also  sliould  be  taken  in  hot  weather  that  the  child  is  not 
exposed  to  too  great  cUrect  heat  from  the  sun,  and  it  should  never  be  kept 
in  a  hot  atmosphere  where  currents  of  fresh  air  cannot  have  access. 

NURSERY-MAIDS.— The  idea  that  the  child  should  be  taken  care 
of  by  an  old,  experienced  nurse  is  a  vicious  one.  The  experience  of 
nurses,  as  a  rule,  is  that  of  ignorance  rather  than  of  intelligence.  Every 
mother,  as  she  is  presumably  more  intelligent  than  the  nurse  whom  she 
employs,  and  is  surely  more  interested  in  the  welfare  of  her  child,  should 
personally  supervise  and  unhesitatingly  investigate  all  that  the  nurse  does 
to  the  cliild.  The  nurse's  ideas  as  to  what  is  ]j  ceded  for  the  cliild's 
hygienic  surroundings,  food,  and  clothing  can  well  be  dispensed  witli. 
The  mother,  learning  from  the  physician  what  is  best  for  her  child,  should 
give  her  directions  to  the  nurse  and  see  that  these  directions  are  strictly 
carried  out.  A  nurse  between  the  ages  of  twenty  and  thirty-five  is  prefer- 
able to  one  who  is  younger  or  older.  She  should  be  neat,  healthy,  strong, 
cheerful,  gentle,  and  patient.  She  should  be  willing  to  refer  small  details 
of  the  nursery  routine  to  the  inother,  as  well  as  those  which  appear  of 
greater  importance.  The  chief  attributes  of  a  good  child's  nurse,  in  our 
opinion,  are  a  desire  to  obey  implicitly  the  orders  which  she  receives 
from  her  mistress,  and  a  temperament  in  harmony  with  the  sensitive 
nervous  organization  of  her  charge.  In  certain  cities,  such  as  New  York, 
Philadelphia,  Buffalo,  and  Boston,  schools  have  been  established  for 
nursery-maids.  An  admiralDle  school  of  this  kind  has  been  carried  on  for 
some  years  at  the  Infants"  Hospital  in  Boston,  where  the  nurses  are 
trained  to  be  servants  as  well  as  nurses,  the  course  lasting  for  one  year. 
When  intelligent  girls  trained  in  this  way  can  be  obtained,  the  preferable 
ag-e  is  between  twenty  and  thirty-five  years. 

MOUTH. — A  protest  should  be  made  against  the  way  in  which  the 
nurse,  and  in  fact  almost  every  one  who  comes  near  the  infant,  put  their 
fingers  into  its  mouth  on  all  occasions.  It  would  seem  as  though  the  m- 
fanfs  mouth  was  considered  by  those  who  ought  to  know  better  as  some- 
thing which  was  especially  made  to  be  felt.  Infants  are  much  more 
likely  to  have  various  diseases  in  their  mouths  than  are  adults,  and  prob- 
ably one  reason  for  this  is  that  dirt  of  all  kinds  is  constantly  being  intro- 
duced into  them.  The  fingers  should  always  be  thoroughly  washed 
before  entering  the  infant's  mouth,  and  yet  unwashed  fingers  are  continu- 
ahy  feeling  the  baby's  gums  to  ascertam  if  a  tooth  can  be  found. 


102  PEDIATllKS. 

The  nurse  should  be  iustrucled  tliat  she  is  never  to  kiss  the  infant  on 
its  mouth,  or  allow  any  one  else  to.  The  germs  of  disease  can  well  be 
transmitted  in  this  way.  It  is  partly  through  ignorance  of  doing  harm, 
and  partly  through  timidity  on  the  part  of  the  mother  in  prohibiting  it, 
that  a  stop  is  not  at  once  put  to  this  bad  habit  of  nurses  and  friends,  and 
it  is  the  physician's  duty  to  warn  mothers  on  this  apparently  trivial  but 
really  important  question,  and  to  tell  them  how  certain  infectious  diseases, 
especially  tuberculosis,  can  be  transmitted  in  this  Avay. 

SCHOOL. — Much  ignorance  of  the  child's  nervous  organization  is 
shown  by  those  "who  should  best  know  how  to  care  for  it,  at  a  period  of 
life  when  its  hygienic  surroundings,  both  mental  and  physical,  are  ex- 
tremely important.  No  one  system  is  good  for  all  children.  We  are 
sure  that  we  have  seen  the  kindergarten  system  do  harm  to  a  number  of 
children,  although  it  seems  to  suit  others.  Each  child  should  be  gauged  for 
itself,  and  not  be  forced  into  any  general  system,  even  if  that  system  has 
proved  to  be  good  for  the  many.  No  time  is  lost,  in  our  opinion,  in  send- 
ing children  to  school  at  a  somewhat  later  age  than  is  usually  supposed  to 
be  necessary.  We  are  continually  obliged  to  take  little  children  out  of 
school  who  are  fretful  and  have  loss  of  appetite.  Neither  parents  nor 
teacher  seem  to  appreciate  that  the  little,  actively  growing  brain  is  over- 
taxed by  too  great  stimulation  and  is  protesting  against  such  treatment  by 
these  general  symptoms.  Many  a  child  is  being  dosed  with  tonics  who 
merely  needs  rest  from  school.  The  parents  should  keep  the  most  rigid 
supervision  over  their  children  while  at  school,  and  notice  from  their  be- 
havior whether  they  are  mentally  tired.  This  supervision  should  not  be 
left  to  the  teachers  alone,  however  interested  they  may  be  in  their  little 
pupils.  It  seems  hardly  necessary  to  state  that  the  school-room  should  be 
well  ventilated,  and  that  at  stated  intervals  during  the  school  hours  the 
windows  should  be  thrown  open  and  the  atmosphere  of  the  room  com- 
^^pletely  changed.  This  should  not,  however,  be  done  with  the  children  in 
the  room.  Attention  should  be  paid  not  only  to  what  the  children  eat  at 
lunch,  but  to  how  and  w^here  the  lunch  is  eaten.  A  child  really  needs 
nothing  but  dry  bread  and  milk  or  water  between  its  meals,  so  far  as  its 
nutrition  and  digestion  are  concerned. 

DEFECTS  OF  POSTURE.— We  can  best  appreciate  the  importance 
of  following  nature  as  closely  as  possible  in  its  methods  of  developing 
young  human  beings  so  as  to  perfect  their  various  functions  to  the  fullest 
extent  by  examining  carefully  a  group  of  malformed  children. 

Back. — The  extreme  flexibility  and  slow  development  of  the  spine 
clearly  point  out  to  us  that  nature  intends  to  leave  its  function  in  abeyance 
and  bring  it  into  use  slowly.  If  the  young  infant  is  allowed  to  sit  or  stand 
at  too  early  an  age,  the  superincumbent  Aveight  of  the  large  head  tends  at 
once  to  exaggerate  the  physiological  curves  of  the  spine  to  a  point  where 
tliey  may  become  pathological. 


NORMAL    DEVELOPMENT.  103 

During  the  first  year  uf  life  tlie  strengtli  of  the  spinal  column  is  slowly 
increasing.  Not  before  the  seventh  or  eighth  month  has  it  acquired  suf- 
ficient rigidity  to  warrant  the  child's  being  allowed  to  sit  up.  Artificial 
methods,  therefore,  of  making  the  young  infant  assume  a  sitting  posture 
at  a  period  of  development  when  the  spine  should  be  comparatively 
straight  should  be  deprecated.  We  have  met  with  numerous  instances 
where  both  parents  and  nurses  were  anxious  to  have  the  infants,  at  a  very 
early  age,  sit  for  quite  a  long  time  strapped  in  small  chairs.  In  like  man- 
ner the  same  infants  were  encouraged  to  stand  and  walk  long  before  the 
apparatus  for  locomotion  was  ready  for  use.  One  may  ask,  how  many  of 
these  indi\dduals  developed  a  spinal  curvature  in  later  childhood  ?  Possi- 
bly the  risk  in  a  perfectly  healtliy  child  may  be  small.  One  often,  how^- 
ever,  in  early  infancy,  cannot  determine  which  individual  may  become 
rhachitic,  and  where  rhachitis  is  present  the  tendency  to  abnormal  curva- 
ture is  well  known. 

We  should,  then,  in  our  advice  as  to  the  proper  physical  management 
of  the  early  years  of  life,  be  guided  by  our  knowledge  of  the  normal 
average  development.  Free  play  for  the  infant's  legs,  when  lying  on  its 
back  in  bed,  should  be  a  point  to  be  noticed  and  considered,  since  we  know 
that  pressing  down  the  legs  causes  strain  and  curvature  in  the  lower  spine. 
Kno\^dng  the  great  lateral  flexibility  of  the  infant's  spine,  we  should  advise 
the  nurse  not  to  hold  the  infant  continually  on  one  side.  Symmetry  of 
development  and  free  opportunity  for  natural  movement  should  be  our 
aim  in  the  management  of  the  infant  from  the  very  earliest  period  of  its 
existence.  Our  knowledge  of  the  great  flexibility  of  the  growing  spine 
provides  us  at  once  ^^dth  a  most  valuable  means  for  treating  lateral  curva- 
ture in  childhood,  and  we  are  continually  seeing  the  benefit  of  encour- 
aging the  promotion  of  elasticity  by  moderate  pressure  and  bending.  A 
case  which  was  under  our  observation  at  the  Infants'  Hospital  beautifully 
illustrates  the  truth  of  Avhat  has  just  been  said. 

A  feeble,  rhachitic  child,  nineteen  months  old,  was  presented  for  treatment  with 
a  marked  lateral  curvature  in  the  dorsal  region,  the  convexity  being  towards  the  right, 
combined  with  decided  rotation,  following  the  type  of  the  worst  adult  cases. 

The  condition  seemed  to  be  purely  the  result  of  habit,  the  patient  having  been 
gaade,  when  very  young,  to  sit  up  beyond  the  limit  of  endurance  of  the  still  undevel- 
oped bones  and  ligaments.  The  treatment  was  based  entirely  on  the  elasticity  of  the 
spine,  and  consisted  simply  of  manipulation  and  recumbency,  resulting  in  a  very 
great  degree  of  improvement  both  as  to  the  curvature  and  the  twisting. 

The  improper  treatment  of  the  young  subject's  spine,  as  in  infants,  for 
instance,  w^here  they  are  carried  altogether  on  one  side,  is  well  recognized 
as  an  important  factor  in  the  etiology  of  rotary  lateral  curvature. 

Remembering  what  has  been  said  regarding  the  ossification  of  the  dif- 
ferent parts  of  the  spinal  column,  it  will  be  understood  that  so  long  as  an 
infant  can  be  made  happy  in  the  prone  position,  whether  in  its  nursery 
or  in  its  carriag-e,  it  will  be  better  for  it  to  be  kept  in  this  position,  always 


104 


PEDIATRICS. 


protecting  the  eyes  when  out  in  the  open  air  from  the  strong  light,  and 
the  face  from  the  wind.  During  the  first  year  when  it  begins  to  sit  up  in 
its  carriage  its  back  should  be  carefully  supported  by  a  pillow. 


Fig.  38  represents  the  harm  which  can  he  done  by  encouraging  children  to  sit  up 
before  their  spinal  columns  are  sufficiently  strong.  The  infant,  six  months  old,  had 
been  made  to  sit  in  a  chair  for  hours  at  a  time,  strapped  in  a  position  which  allowed 
it  to  use  its  arms,  but  such  as  to  render  it  impossible  to  fall  baclc  and  rest  itself. 
The  exaggerated  curve  of  its  back  corresponds  to  that  which  would  be  seen  normally 
at  birtli.      Sur-h  a  curve  is  shown  in  Fig.  3  (1),  page  23.      If  this  infant  liad  not  been 

Fig.  38. 


Posterior  sianal  curvature  from  sitting  too  soon. 

made  to  sit  until  it  had  developed  sufficiently  to  acquire  the  physiological  curve  (2),  it 
would  not  at  this  age  show  any  spinal  curvature.  It  had,  however,  through  improper 
treatment  i-eacquired  the  posterior  curvature  (1)  of  the  early  hours  of  life. 

As  the  child  grows  older,  weak  undeveloped  muscles  have  a  tendency 
to  allow  lateral  and  posterior  curvatures  to  be  produced.  Habit,  of  course, 
has  much  to  do  with  these  faulty  positions  of  later  childhood. 

Figs.  39  and  40  represent  a  girl  aged  four  and  one-half  years,  with  a  lateral  cui-va- 
ture,  not  from  disease  of  the  spine,  but  one  which  is  usually  explained  as  a  result  of 
superincumbent  weight  coming  upon  muscles  which  are  unable  to  support  it  properly. 

On  looking  at  her  from  behind,  the  curve  which  the  line  of  the  spinal  column 
takes  to  the  right  in  the  dorsal  region  is  quite  distinct.  On  looking  at  this  same  child 
in  front,  the  right  shoulder  is  seen  to  be  higher  than  the  left,  and  the  whole  thorax  is 
in  a  distorted  position.  These  deformities  are  always  more  readily  recognized  by 
looking  at  the  child  in  front  and  preferably  across  the  room,  as  the  outline  of  the  chest 
and  hips  is  much  more  clearly  defined  on  the  anterior  aspect  of  the  body  than  on  the 


NORMAL    DEVELOPMENT. 


105 


posterior.  Posteriorly,  in  cases  even  of  the  slightest  lateral  curvature,  one  notices  the 
difference  in  the  level  of  the  angles  of  the  scapulae.  This  child  stooped,  and  had 
what  is  commonly  called  round  shoulders. 

In  any  case  of  round  shoulders  lateral  curvature  should  be  thought  of 
and  carefully  eliminated. 

Faulty  attitudes  in  sitting  and  standing  play  a  great  role  in  producing 
these  curvatures.  We  must,  however,  acknowledge  that  such  spinal  curva- 
FiG.  39.  Fig.  40. 


Lateral  curvature  of  the  spine.    Child  4,^^  years  old. 

tures  have  been  differently  explained  on  the  ground  that  they  are  the 
result  of  a  lack  of  development  of  all  the  tissues  upon  one  side  of  the 
spine.  Other  explanations  have  also  been  given  ;  but  in  certain  individual 
cases  it  is  impossible  to  formulate  any  reasonable  cause  for  the  curvature. 
Legs. — At  birth  the  infant's  legs  are  curved  rather  than  straight,  as  is 
seen  in  Figs.  26  and  27,  facing  page  82.  The  natural  tendency  of  the 
growth  of  the  legs  is  to  become  straight,  but  if  the  child  is  encouraged  to 
stand  and  walk  too  soon,  especiahy  if  the  bones  have  not  been  properly 
nourished,  the  weight  of  the  head  and  trunk  becomes  too  great  to  be 
supported  by  the  legs,  which  curve  outward  in  the  form  of  an  ellipse,  a 
condition  which  is  called  "bow-legs."  The  deformity  of  "knock-knee," 
in  which  the  leg  at  the  knee  bends  in  rather  than  bows  out,  may  occur 
from  simple  \veakness,  but  is  rare  except  in  rhachitis,  under  which  it  will 
be  more  fully  described. 


DIVISION  11. 

FEEDING. 

GENERAL    PRINCIPLES. 

Just  as  the  highest  aim  of  medical  art  should  be  directed  to  the  prov- 
ince of  preventive  medicine,  so  the  highest  and  most  practical  branch  of 
preventive  medicine  should  consist  of  the  study  of  the  best  means  for 
starting  young  human  beings  in  life.  They  should  be  preserved  from  the 
perils  which  surround  the  early  hours  of  their  existence,  and  be  given 
strength  and  vigor  to  resist  the  attacks  which  must  inevitably  be  made  on 
their  vitality,  and  which  are  greater  and  more  dangerous  in  inverse  pro- 
portion to  their  age.  With  these  objects  in  view,  the  preventive  medicine 
of  early  life  becomes  pre-eminently  the  intelligent  management  of  the 
nutriment  which  enables  young  human  beings  to  breathe  and  grow  and 
live.  In  fact,  it  is  a  proper  or  an  improper  nutriment  which  makes  or 
mars  the  perfection  of  the  coming  generations.  The  feeding  of  infants  is, 
then,  the  subject  of  all  others  which  should  interest  and  incite  to  research 
all  who  are  working  in  the  domain  of  pediatrics,  and  in  fact  as  a  matter  of 
public  health,  a  practical  knowledge  of  the  modern  methods  of  infant 
feeding  becomes  an  imperative-  duty.  The  subject  is  a  great  one,  and  is 
^ — ^vorthy  of  the  most  careful  study.  It  should  be  taken  up  carefully. 
It  should  be  dealt  with  broadly.  AVe  must  acknowledge  that  in  the 
status  of  feeding,  as  it  has  existed  up  to  the  last  few  years,  the  aver- 
age human  breast-fed  infant  was  more  likely  to  live,  other  conditions 
being  the  same,  than  the  infant  which  was  fed  by  any  other  method.  But 
we  must  remember  that  the  latest  investigations  of  this  subject  show  very 
clearly  that  it  is  not  human  milk  as  a  whole  which  is  pre-eminently  good, 
but  that  it  is  a  varied  combination  of  the  different  elements  of  the  milk 
which  makes  it  the  best  food  during  the  first  year  of  life.  It  is  our  prov- 
ince to  study  and  make  use  of  .these  elements  of  the  food,  which  were 
once  somewhat  mysterious,  but  which  are  now  rapidly  becoming  known 
through  the  work  of  patient  and  careful  investigators. 

In  reviewing  the  immense  amount  of  literature  which  has  accumulated 
on  the  subject  of  feeding,  we  find  that  the  superiority  of  human  milk  to 
all  other  kinds  of  infant  food  in  the  early  months  of  life  is  acknowledged 
106 


FEEDING.  107 

so  generally  that  it  has  become  an  axiom.  On  the  other  hand,  the 
opinions  expressed  regarding  artificial  feeding  in  the  past  are  so  diverse 
and  so  opposed  to  one  another  that  it  is  evident  that  much  which  has  in 
former  years  been  taught  must  be  unlearned,  or  rather  admitted  to  be 
untrue,  before  we  can  expect  to  make  any  decided  progress  in  this  most 
difficult  subject. 

The  feeding  problem  is  one  which  is  surrounded  with  many  difficul- 
ties on  account  of  the  great  diversity  of  individual  circumstances  and  idio- 
syncrasies. Certain  infants  thrive  on  peculiar  mixtures  which  are  not 
adapted  to  infants  as  a  class.  Many  will  not  thrive  on  that  food  which 
nature  has  provided  for  them,  and  the  well-being  of  an  infant  will  depend 
much  upon  the  circumstances  by  which  it  is  surrounded,  such  as  affluence 
or  poverty,  country  or  city  Kfe.  The  constituents  of  the  nutriment  which 
nature  has  provided  for  the  offspring  of  all  mammals  in  the  early  period 
of  their  existence  is  essentially  animal  and  never  vegetable.  It  is  therefore 
evident  that  an  animal  food,  entirely  and  freshly  derived  from  animal  and 
not  vegetable  sources,  has  been  proved  to  be  the  nutriment  on  which  the 
greatest  number  of  human  beings  live  and  the  least  number  die. 

MAMMARY  GLAND. — In  regard  to  the  early  months  of  life,  a 
knowledge  of  the  changes  which  take  place  in  the  mammary  gland  from 
many  causes  is  of  vital  importance  and  must  be  kept  in  view.  The 
methods  of  modifying  the  milk  in  the  mammary  gland,  however  limited 
in  their  scope,  should  be  carefully  investigated  and  adapted  to  the  indi- 
vidual infant  according  to  its  age  and  size  and  general  physical  condition. 
The  manmiary  gland,  in  its  perfect  state,  uninfluenced  by  disease  or  ner- 
vous disturbance,  or  by  the  improper  living  of  the  mother,  is  a  beautifully 
adapted  piece  of  mechanism  constructed  for  the  elaboration  and  secretion 
of  an  animal  food.  When  in  equilibrium  it  represents  the  highest  type 
of  a  living  machine  adapted  for  a  special  purpose, — mechanically,  physio- 
logically, and  economically.  When  from  any  cause  this  sensitive  machinery 
is  thrown  out  of  equilibrium,  its  product  is  at  once  changed,  sometimes 
slightly,  but  again  to  such  an  extent  that  the  most  disastrous  consequences 
may  follow  when  it  is  taken  by  the  young  consumer.  The  breasts  of 
all  mammals  are  elaborators  and  producers.  They  are  not  storehouses 
for  preserving  sustenance  until  it  is  needed.  They  are  delicately  con- 
structed mills,  turning  out,  when  demand  is  made  for  it,  a  product  which 
has  been  directly  formed  within  their  walls  from  material  which  has  been 
brought  through  their  porials  from  various  parts  of  the  economy.  The 
breast  is  a  compound  racemose  gland,  lined  with  glandular  epithelium, 
which  forms  sugar,  fats,  and  proteids,  and  these  are  mixed  with  water  and 
salts  from  the  blood.  The  epithelial  cells  are  so  finely  organized,  and  so 
sensitive  with  their  minute  nerve  connections,  that  changes  of  atmosphere, 
changes  in  food,  the  emotions,  fatigue,  sickness,  the  catamenia,  pregnancy, 
and  many  other  influences,  throw  their  mechanism  out  of  equilibrium 
most  readily,  and  change   essentially  the  proportions  of  their  finished 


110  PKD I  ATI UC^^. 

Gordon  for  placing  at  our  disposal  his  practical  observations  on  the  feed- 
ing, breeding,  and  lactation  of  cows. 

The  first  nutritive  period  represents  the  first  twelve  months  of  life. 
and  is  obviously  the  most  important  one  of  the  three.  In  this  period  the 
infant  may  be  fed  by  a  number  of  methods.  It  may  be  nursed  by  its 
mother,  or  a  wet-nurse,  or  an  animal,  or  it  may  be  nourished  by  food 
especially  prepared  from  the  milk  of  one  of  these. 

I.     MATERNAL  FEEDING. 

The  first  of  these  methods,  the  maternal,  is,  as  a  rule,  far  superior  to 
any  other,  and  is  the  one  from  which  in  almost  every  particular  all  others 
should  be  copied. 

Normal  Maternal  Conditions. — The  assumption  that  the  maternal  is, 
when  normal,  the  ideal  source  of  infant  food-supply  presupposes  many  im- 
portant conditions  concerning  the  mother  and  the  function  of  her  mam- 
mary glands.  She  should  be  strong  and  healthy,  of  an  even,  happy  tem- 
perament, desirous  of  nursing  her  infant,  and  have  time  to  devote  herself 
to  this  special  duty  during  the  whole  period  of  her  lactation.  She  should 
have  a  sufficient  supply  of  milk,  and  should  be  willing  to  regulate  her  diet, 
her  exercise  and  her  sleep  according  to  the  rules  which  will  best  fit  her 
for  her  task.  These  may  be  said  to  be  the  ideal  conditions  which  we 
endeavor  to  obtain  for  an  infant  which  is  to  be  nursed  under  the  most 
favorable  circumstances.  It  is  true  that  women  who  are  far  from  vigorous 
nurse  their  infants  with  seemingly  good  results,  and  that  a  frail,  delicate- 
looking  mother  may  have  an  abundant  supply  of  good  milk.  These  are 
exceptions,  however,  which  make  the  principles  just  stated  all  the  more 
true.  We  must  have  some  general  principles  to  guide  us  in  our  endeavor 
to  perfect  the  nutriment  of  infants  as  a  class,  or  we  shall  surely  in  many 
instances  do  serious  harm  to  the  individual 

Contra-Indications  to  Maternal  Feeding. — With  few  exceptions,  the 
mothers  who  have  uncontrollable  temperaments,  who  are  unhappy,  who 
are  unwilling  to  nurse  their  infants,  who  are  hurried  in  the  details  of 
their  life,  who  are  irregular  in  their  periods  of  rest  and  in  their  diet  and 
exercise,  are  unfit  to  act  as  the  source  of  food-supply  for  their  infants. 
Even  if  their  milk  happens  to  be  sufficient  in  quantity,  it  will  probably  be 
so  changeable  in  quality  as  to  be  a  source  of  discomfort  and  even  of 
danger  rather  than  the  best  nutriment  for  their  offspring.  It  is  far  better 
for  such  mothers  not  to  attempt  to  nurse,  but  to  adopt  some  other  method 
of  feeding.  It  is  of  still  greater  importance  that  mothers  who  are  suffering 
from  some  chronic  disease,  or  one  which  their  infants  may  directly  inherit, 
should  give  up  all  thoughts  of  nursing.  When  there  is  no  question  of 
disease  in  the  mother,  it  is  our  duty  to  investigate,  and,  if  possible,  to 
counteract  the  other  contra-indications  to  nursing,  often  only  caused 
through  ignorance  of  what  to  us  seem  very  simple  truths,  but  which  to 
the  young  mother  are  enveloped  in  mystery.     There  is,  then,  a  double 


FEEDING.  ni 

necessity  for  studying  in  the  closest  detail  tlie  conditions  wliich  constitute 
normal  lactation  ;  first,  that,  knowing  what  is  normal,  we  should  rec- 
ognize what  is  abnormal,  and,  by  the  intelligent  use  of  our  knowledge, 
render  possible  an  apparently  unsuccessful  attempt  to  nurse  ;  secondly, 
that  we  may  know  exactly  on  what  the  normal  and  vital  conditions  of 
successful  nursing  depend,  in  order  that  we  may  understand  what  we 
should  copy  in  substitute  feeding. 

Nursing. — The  natural  method  of  feeding  is  by  sucking.  The  infant 
should  be  placed  in  a  comfortable  position  in  its  mother's  arms,  with  its 
head  and  back  supported.  It  should  be  made  at  once  to  understand  that 
it  is  to  begin  its  meal  as  soon  as  the  breast  is  offered  to  it,  and  continue, 
of  course  with  breathing-spells,  until  the  meal  is  finished.  The  mother 
should  herself  preferably  be  sitting,  as  she  can  thus  best  manage  and 
control  the  infant  if  it  is  incHned  to  be  restless. 

The  formation  of  the  lips  and  buccal  cavity  are  adapted  to  the 
mechanism  of  suction.  The  breast  is  so  organized  that  it  provides  a 
fresh  supply  of  food  at  the  required  intervals.  It  prevents  fermentation 
of  the  food  before  it  enters  the  infant's  mouth,  while  at  the  same  time 
the  suction  incites  to  action  both  the  necessary  digestive  fluids  of  the 
infant  and  the  function  of  the  gland  itself.  The  gland  avoids  a  vacuum 
by  collapsing  as  it  is  gradually  emptied,  and  allows  the  food  to  flow  con- 
tinuously, thus  obviating  the  tendency  to  exhaustion  of  the  infant  and 
prolongation  of  the  nursing-time  which  necessarily  accompanies  a  re- 
tarded flow  of  the  milk.  Finally,  the  breast  is  practically  self-regulated 
as  to  the  amount  Avliich  it  is  recpaired  to  provide  according  to  the  infant's 
age.  A  healthy  infant  should  empty  the  breast  with  easy  and  uninter- 
rupted sucking  in  about  fifteen  to  twenty  minutes. 

Nipples. — The  care  of  the  breasts,  if  free  from  fissures  and  excoria- 
tions, recpiires  nothing  more  than  scrupulous  cleanliness.  They  should  be 
bathed  before  and  after  nursing  with  cold  water  which  has  been  boiled. 
A  piece  of  folded  sterile  linen  or  some  other  soft  sterile  absorbent  material 
should  be  kept  on  the  nipples  to  protect  them  from  contact  with  the 
clothing  and  to  absorb  any  overflow  from  the  breasts.  In  certain  cases 
the  mother's  nipple  is  so  small  or  depressed  that  it  is  a  source  of  much 
annoyance  to  the  infant,  and  at  times  this  interferes  so  seriously  with  its 
obtaining  the  proper  foodrsupply  that  its  nutrition  suffers,  and  some 
other  method  than  nursing  has  to  be  substituted.  It  is  here  that  the 
ingenuity  of  the  physician  is  taxed  to  its  utmost.  Every  kind  of  de\ice 
may  fail,  and  it  is  necessary  patiently  to  try  one  after  the  other  be- 
fore deciding  to  give  up  the  nursing.  Nipple-shields  should  be  tried, 
and  will  sometimes  obviate  the  difficulty.  If  the  shield  is  partially  filled 
with  breast-milk  before  applying,  the  infant  will  nurse  from  it  more 
readily.  We  should,  however,  always  impress  upon  the  mother  the  fact 
that  the  value  of  her  milk  as  a  food  may  be  entirely  destroyed  if  foreign 
elements  are  allowed  to  enter  with  it  into  her  infant's  mouth.  This  simply 
means  extreme  cleanliness  of  the  glass  shield  and  rubber  nipple. 


112  PEDIATRICS. 

When  the  nipples  are  very  tender  and  cause  great  discomfort  to  the 
mother  during  the  nursing,  their  condition  frequently  becomes  so  serious 
an  obstacle  as  to  prevent  nursing  altogether.  This  change,  however, 
should  not  be  thought  of  for  at  least  several  days,  or  until  it  is  absolutely 
certain  that  the  exquisite  pain  is  more  than  the  mother  is  willing  or  able 
to  endure.  It  is  often  the  case  that  after  a  little  time  of  the  greatest  suf- 
fering from  tender  or  excoriated  nipples  the  whole  difficulty  will  pass 
away  and  tlie  mother  be  able  to  nurse  her  infant  with  comfort.  Fissures 
of  moderate  severity  should  be  treated  by  washing  with  sterile  water  after 
the  nursing,  and  by  applying  boracic  acid  ointment,  or  the  compound  tinct- 
ure of  benzoin.  In  more  severe  cases  nitrate  of  silver  should  be  applied  to 
the  fissures,  the  healthy  skin  being  protected.  Care  should  be  taken  not  to 
apply  remedies  which  might  injure  the  infant.  Where  the  nipples  show  a 
tendency  to  be  dry  and  hard,  it  is  well  to  apply  some  simple  ointment  once 
or  twice  a  day  during  the  last  few  weeks  of  the  pregnancy.  Astringents, 
as  a  rule,  should  not  be  used.  Bathing  with  cold  water  before  and  after 
the  nursing,  and  thus  keeping  the  tissues  in  a  healthy  condition,  is  a 
valuable  prophylactic  measure. 

Mastitis. — Another  trouble  which  may  arise  during  the  nursing  period 
is  a  disturbance  of  the  mammary  gland  itself,  sometimes  amounting  merely 
to  a  stasis  in  its  milk  production,  but  again  going  on  to  inflammation.  The 
latter  is  a  serious  matter,  and  should  at  once  be  placed  in  the  hands  of  a 
skilful  surgeon.  The  former  condition  requires  great  care  in  its  manage- 
ment. Gentle  massage  from  the  periphery  of  the  gland  towards  the 
nipple,  amounting  in  fact  to  merely  a  delicate  stroking  with  the  ends  of 
the  fingers,  is  an  important  part  of  the  treatment.  The  breast  should  be 
withheld  from  the  infant  for  about  twenty-four  hours,  and  the  milk  from 
time  to  time  drawn  in  small  quantities  by  means  of  a  properly  adjusted 
breast-pump.  The  breast  should  also  be  carefully  supported  by  a  swathe. 
If  these  measures  are  begun  as  soon  as  there  are  any  indications  of  dis- 
turbance in  the  breast,  these  abnormal  conditions  soon  disappear.  The 
indications  referred  to  consist  in  the  appearance  of  hard  swellings  in  place 
of  the  usual  soft  elastic  condition  of  the  milk  glands.  These  swellings 
may  occur  without  any  especial  pain,  but  on  palpation  they  are  usually 
tender  to  a  greater  or  less  degree. 

In  regard  to  the  relation  of  micrococci  to  inflammation  of  the  breast, 
according  to  Zweifel  and  Doderlein  there  are  in  mastitis  two  varieties  of 
organisms,  the  staphylococcus  pyogenes  aureus  and  the  streptococcus 
pyogenes,  but  never  the  staphylococcus  pyogenes  albus.  '  They  admit 
that  other  varieties  may  perhaps  be  found  on  closer  investigation,  but  at 
the  same  time  they  consider  it  striking  that  in  all  their  cases  there  were 
never  any  local  or  general  symptoms  caused  by  the  staphylococcus  pyo- 
genes albus,  although  that  they  were  virulent  was  proved  by  their  inocu- 
lation of  mice.  There  is  not  much  doubt  that  these  pathogenic  organisms 
gain  access  to  the  gland  through  the  nipple.     The  infant  may  not  be  able 


FEEDING. 


113 


Fig 


to  hold  the  nipple  with  sufficient  firmness  on  account  of  some  abnormal 
condition  of  the  nipple  itself.  Under  certain  circumstances,  even  when 
the  nipple  is  well  formed,  the  infant  has  insufficient  suction-power  to  obtain 
its  food,  though  the  food  itself  may  be  perfectly  adapted  to  its  digestion.  In 
these  cases  we  often  find  that  it  cannot  or  will  not  be  induced  to  obtain  its 
food  through  a  shield  and  rubber  nipple,  as  shown  in  the  following  case : 

All  infant,  seven  months  old,  was  dying  of  starvation,  as  we  had  not  heen  able  to 
prepare  for  it  a  food  which  it  could  digest  and  thrive  on.  (This  was  before  milk  labo- 
ratories were  established.)  It  was  totally  unable  to  nurse,  although  the  breast-milk  was 
a  good  one  and  agreed  with  it  perfectly  when  it  was  introduced  into  its  mouth  with  a 
spoon.  The  milk  was  pumped  fi'om  the  breasts  at  regular  intervals  and  given  to  it 
from  a  bottle  for  over  three  months  with  the  greatest  success,  the  infant  thriving,  and  at 
the  end  of  that  time  being  in  a  perfectly  healthy  condition. 

Breast-Pump. — In  regard  to  the  use  of  the  breast-pump  there  is  a  great 
difference  of  opinion,  but  we  believe  that  those  who  have  opposed  its  use 
have  been  influenced  to  a  great  degree  by  what  they  have  seen  in  their 
hospital  practice,  and  also  by  the  views  of  others  who  have,  in  like  man- 
ner, met  with  unfortunate  results  in  lying- 
in  hospitals.  It  is  well  known  that  all 
inflammatory  conditions  about  the  breast 
are  more  likely  to  occur  in  hospitals  than 
under  conditions  in  which  the  woman  is 
less  hkely  to  be  exposed  to  pathogenic 
organisms.  This  should  be  taken  into 
account  when  we  are  deciding  whether  or 
not  to  use  a  breast-pump.  In  our  experi- 
ence, acquired  in  a  great  degree  from 
private  practice,  where  every  precaution 
in  regard  to  cleanliness  and  asepsis  could 
be  obtained,  we  have  never  met  with  any 
bad  results  from  the  use  of  the  pump. 
Fig.  41  represents  the  form  of  pump  which 
is  safe  and  useful. 

The  apparatus  should  be  one  which 
can  be  carefully  cleansed,  and  should, 
therefore,  preferably  be  made  of  glass. 
Xo  one  special  pump  will,  in  all  probabil- 
ity, suit  every  case,  and  it  is  of  importance 
that  one  should  use  the  greatest  care  in 
adapting  the  pump  to  the  individual. 
When  applied  to  the  breast  it  should  cause  little  or  no  pain  or  discomfort. 
The  part  which  is  adapted  to  the  nipple  is  like  an  ordinary  nipple-shield. 
This  is  attached  to  a  glass  bulb,  into  which  the  milk  falls  as  it  is  drawn 
from  the  breast.     The  mechanism  is  very  simple.     A  vacuum  can  be  pro- 

8 


lircaBt-punip. 


114  PEDIATRICS. 

duced  in  the  glass  bulb  by  means  of  suction  through  a  rubber  tube 
attached  to  a  rubber  bulb  with  its  valve  working  backward. 

MILK. — In  the  products  of  the  mammary  glands  of  all  mammals  we 
find  substances  representing  the  great  subdivisions  of  food-stuffs, — that 
is,  fats,  carbohydrates,  proteids,  salts,  and  water, — but  there  is  considerable 
variation  in  the  relative  proportions  in  which  they  occur  in  the  milk  of 
different  mammals,  and,  as  regards  their  ultimate  chemical  analysis,  much 
is  still  to  be  investigated  by  the  analytical  and  physiological  chemists. 
It  is  primarily  on  the  results  of  their  work  that  the  advances  in  the  scientific 
feeding  of  infants  and  children  are  to  be  made.  In  general  the  composi- 
tion of  milk  consists  of/afe,  of  carbohydrates  in  the  form  of  lactose  or  milk- 
sugar,  of  proteids  in  the  form  of  caseinogen  (casein)  and  the  tvhey ^proteids ^ 
consisting  chiefly  of  lactalbumin  and  the  nitrogenous  extractives,  of  salts^ 
and  of  water.  It  is  the  combination  of  these  various  elements  and  differ- 
ences in  the  chemical  nature  of  some  of  the  ingredients  which  make  the 
resulting  product  characteristic  of  the  especial  mammal. 

Formation. — The  more  recent  investigations  on  the  physiological 
action  of  the  mammary  glands  tend  to  show  that  the  actually  dissolved 
constituents  of  milk  do  not  have  their  source  in  a  simple  process  of  filtra- 
tion or  diffusion  from  the  blood,  but  are  dependent  upon  a  specific 
secretory  activity  of  the  glandular  elements  (Hammarsten).  Evidence  of 
this  lies  in  the  fact  that  milk-sugar  is  not  found  in  the  blood,  tliat  the 
lactalbumin  is  not  identical  with  serumalbumin,  and  that  the  mineral 
bodies  exist  in  milk  in  different  proportions  from  those  in  the  blood- 
serum  of  the  same  animal.  According  to  Foster,  milk  is  the  product  of 
the  activity  of  certain  protoplasmic  cells,  occurring  in  the  epithelium  of 
the  mammary  gland.  These  cells  are  rich  in  proteids  and  nucleoproteids, 
which  seem  to  be  the  source  of  the  casein  or  its  mother-substance.  The 
protoplasm  itself  becomes  a  constituent  of  the  secretion  (Hammarsten). 

The  fat  of  milk  is  produced  within  the  protoplasm  of  the  epithelial 
cells,  and  is  set  free  by  the  destruction  of  the  fat  globules ;  a  portion  of 
the  fat  is  probably  taken  up  by  the  glands  tliemselves  from  the  blood  and 
eUminated  with  its  secretion.  That  this  is  possible  has  been  proved  by  the 
experiments  of  Winternitz,  in  which  the  passage  of  iodized  fats  in  the  milk 
was  noted ;  and  similar  observations  were  made  by  Spampani  and  Daddi 
with  sesame  oil.  Microscopically,  the  fat  can  be  seen  to  be  gathered  in 
the  epithelial  cell  in  the  same  way  as  in  a  fat  cell  of  the  adipose  tissue, 
and  to  be  discharged  into  the  channels  of  the  gland  either  by  a  breaking 
up  of  the  cells  or  by  a  contractile  extension  very  similar  to  that  which 
takes  place  when  an  aincjeba  ejects  its  digested  food.  A  formation  of  fats 
from  carbohydrates  in  the  animal  organism  is  now  positively  proved,  and 
it  is  possible  that  the  milk  glands  themselves  also  produce  fats  from  the 
carbohydrates  brought  to  them  by  the  blood  (Hammarsten).  It  is  also 
well  established  that  a  part  of  the  fat  of  milk  is  produced  from  proteid 
material ;  but  the  question  in  all  these  instances  as  to  how  much  fat  is 


FEEDING.  115 

produced  by  the  secretory  mechanism  of  the  milk  glands,  and  how  much 
is  obtained  from  other  organs  and  tissues  and  eliminated  from  the  blood 
by  the  milk  glands,  has  not  been  determined. 

The  origin  of  the  milk-sugar  is  not  known.  That  it  is  formed  in  the 
cell  protoplasm  is  indicated  by  the  fact  that  it  is  not  found  in  the  blood 
itself,  and  may  be  maintained  in  abundance  in  the  milk  of  carnivora 
which  are  fed  exclusively  on  lean  meat.  One  of  the  nucleoproteids  men- 
tioned above  as  occurring  in  the  cell  protoplasm  yields  a  reducing  sub- 
stance when  boiled  with  dilute  acids,  and  future  investigations  may  show 
some  relation  between  this  substance  and  lactose. 

Nervous  Disturbances  affecting  the  Milk. — The  secretion  and  elimi- 
nation of  milk  are  very  evidently  under  the  control  of  the  nervous  system, 
which  produces  marked  changes  in  both  the  quantity  and  the  quality  of  the 
mammary  product  in  proportion  to  the  relative  nervous  excitability  of  the 
special  mammal.  Women  are  especially  sensitive  in  this  respect,  and  when 
living  in  the  midst  of  our  modern  civilization,  so  harmful  for  the  produc- 
tion of  good  nursing,  present  an  exaggerated  example  of  disturbance  of 
the  equipoise  of  the  mammary  gland.  The  chemistry  of  the  equipoise 
and  lack  of  equipoise  of  the  mammary  product  appears  to  be  closely  con- 
nected with  its  proteid  element.  This  element  is  known  to  be  a  com- 
pound one  and  decidedly  complex,  but  for  purposes  of  illustration  we  can 
safely  say  that  the  word  proteid  is  a  general  term,  which  includes  casein- 
ogen  and  lactalbumin  and  the  nitrogenous  extractives ;  also  that  these 
factors  of  the  complete  whole  vary  in  their  proportions  to  each  other 
according  as  the  mammary  function  is  or  is  not  in  a  state  of  equipoise.  In 
the  colostrum  period,  and  probably  in  the  analogous  periods  represented 
by  the  abnormal  conditions  already  spoken  of,  the  lactalbumin  is  in  excess 
in  proportion  to  the  caseinogen,  while  as  the  equipoise  of  the  function 
becomes  more  complete  the  caseinogen  is  increased  proportionately  to  the 
lactalbumin.  Probably  at  the  end  of  lactation,  as  in  the  beginning,  we 
shall  find  this  same  condition  of  richness  of  lactalbumin  and  deficiency  of 
caseinogen.  This  increase  of  the  lactalbumin  at  the  expense  of  the  casein- 
ogen explains  how  the  excretory  function  of  the  gland  at  times  becomes 
more  prominent  than  the  secretory. 

These  nervous  disturbances,  however,  may  also  cause  an  over-produc- 
tion of  the  total  proteids,  as  shown  by  their  percentages.  In  some  cases 
also  the  fat  has  been  found  to  be  much  reduced  in  its  total  percentage. 
Instances  of  this  have  arisen  when,  as  observed  by  Zukowski,  seasons  of 
fasting  with  their  accompanying  excitement  of  the  emotions  have  induced 
such  a  disturbance  of  the  equilibrium  of  the  milk  that  the  fat  has  been 
found  to  be  decreased  to  the  low  percentage  of  0.88,  with  the  result  that 
the  infant  has  become  sick  and  given  evidence  of  impaired  nutrition. 
These  same  nervous  influences  in  all  probability  have  to  a  greater  or  less 
degree  their  analogy  in  the  milk-product  of  all  mammals. 

COLOSTRUM. — During  the  early  days  of  lactation  the   mammary 


116  PEDIATRICS. 

gland  secretes  a  fluid  which  differs  somewhat  from  that  which  is  produced 
later.  The  milk  at  this  period  is  called  colostrvm,  and  the  period  is  called 
the  colostrum  period,  on  account  of  the  presence  in  the  milk  of  certain  ele- 
ments called  colostrum  corpuscles.  These  cells  measure  from  12  to  22  u 
in  diameter,  and  show  a  sniall.  irregular,  extensively  degenerated  nucleus. 
Their  protoplasm  contains  lai^e  and  small  granules,  Avhich  show  the  pro- 
teid  reactions,  and  are  not  stained  by  acid,  basic,  or  neutral  dyes  ;  a  few 
of  the  granules  which  stahi  by  osmic  acid  are  probably  fatty.  The  cor- 
puscles have  been  described  by  Czerny  as  lymphoid  cells,  whose  function 
is  to  absorb  and  reconstruct  unused  milk  globules  and  to  convey  them 
from  the  milk  glands  into  the  lymph-channels.  They  disappear  from  the 
mother's  milk  in  a  week  or  ten  days  after  birth.  If  they  continue  in  the 
milk  into  the  third  week,  or  return  at  any  time  during  lactation,  they  almost 
invariably  cause  disturbance  of  the  infant's  digestion,  and  become  an  indi- 
cation for  a  temporary  suspension  of  nursing.  If  they  persist  for  any 
length  of  time,  the  mother's  milk  is  manifestly  not  suitable  for  the  intant, 
and  a  substitute  should  be  provided. 

Analyses  of  Colostrum. — Five  analyses  of  milk,  made  by  Pfeiff'er,  from 
specimens  obtained  during  the  first  three  days  of  lactation,  gave  the  follow- 
ing results : 

Proteids 5.71 

Fat  ....  ^ 2.04 

Sugar 3.74 

Salts 0.28 

Water 88.23 

100.00 

The  most  recent  study  of  human  colostrum  has  been  made  by  Wood- 
ward, who  analyzed  the  colostrum  of  six  nursing  women,  using  in  each 
instance  the  combined  twenty-four  hours'  amount  of  the  middle  milk, 
and  following  each  case  from  three  to  seven  days.  He  concludes  as  a 
result  of  his  investigations  that  colostrum  corpuscles  are  not  always 
found  in  the  so-called  colostrum-milk ;  that  when  they  are  present  the 
percentage  of  proteids  is  higher,  and  as  they  disappear  the  proteid  per- 
centage drops.  In  all  his  cases  there  was  a  loss  of  weight  in  the  infants 
varying  from  eight  to  twelve  ounces,  whether  the  colostrum  corpuscles 
were  present  or  absent ;  when  they  were  8i)sent  a  high  temperature  in 
the  mother  was  noted.  The  results  of  his  analyses  may  be  best  seen 
in  the  following  table  : 


TABLE  24. 


General  Average  of 
Twenty-s'x  Analyses. 


Color YelIo\vish. 

Eeaction Alkaline.  '       

Specific  gravity 1024  to  1034.  1029. 5 

Fats 2.0  to  5.3  per  cent.  4.0  per  cent. 

Proteids 1.64  to  2.22  per  cent.  1.9  per  cent. 

Ash 0.14  to  0.42  per  cent.  0.2  per  cent. 

Total  solid; 10.18  to  13.65  per  cent.  12.5  per  cent. 

Lactose  (calculated  i 5.6  to  7.4  per  cent.  G.5  percent. 

Water 87.5  per  cent 


Pig.  42. 


Colostrum  milk  from  cow.    (Photo-micrograph.) 


Pig.  43. 


Colostrum,  milk  from  wom.an.    (Photo-micrograph.) 


FEEDING.  117 

The  observations  of  Townsend  have  shown  that  the  infants  of  mul- 
tiparfe  do  not  lose  as  much  weight  in  the  colostrum  period  as  those  of 
primiparae,  and  also  that  the  shorter  the  colostrum  period  the  smaller 
the  so-called  physiological  loss  of  weight  in  the  new-born. 

Colostrum  is  also  supposed  to  have  a  laxative  effect,  and  so  to  aid  in 
removing  the  meconium.  AN'hether  this  action  is  of  any  advantage  to  the 
infant  is  doubtful.  The  appearance  of  the  colostrum  corpuscles  is  simply 
an  indication  that  the  equilibrium  of  the  mammary  gland  has  not  been 
established,  or  has  been  disturbed.  It  may  be  that  the  not  infrequent 
disturbance  of  the  infant's  digestion  in  the  early  weeks  of  nursing  is  pro- 
duced by  an  exaggerated  abnormal  condition  occurring  in  the  colostrum 
period,  as  well  as  by  the  return  of  the  colostrum  at  irregular  intervals. 
The  apparent  immunity  of  the  infant  so  often  seen  in  the  first  few  days  is 
probalDJy  partly  due  to  its  scanty  secretion  and  partly  to  the  deficiency  of 
hydrochloric  acid,  which  allows  the  milk  to  pass  quickly  into  the  duodenum 
without  the  formation  of  the  hard  curds  of  paracasein.  The  disturbing 
results  of  the  colostrum  when  its  period  is  prolonged  may  possibly  be 
dependent  upon  the  increased  secretion  of  the  milk  and  the  consequent 
larger  ingestion  of  the  excessive  amount  of  proteids,  which  may  show  an 
analysis  as  high  as  five  or  six  per  cent,  and  thus  prove  too  great  a  tax  on 
the  undeveloped  function  of  the  stomach. 

HUMAN  MILK. — Beyond  the  general  conditions  affecting  the  mam- 
mary products  of  the  mother,  which  have  already  been  spoken  of,  Ave 
know  of  no  way  of  increasing  the  flow  of  milk.  We  have  little  confidence 
in  galactagogues  in  the  form  of  drugs  or  special  foods,  for  their  number 
betrays  their  inefficiency.  The  milk  becomes  lessened  from  many  causes, 
some  of  which  are  identical  with  those  which  commonly  produce  any  dis- 
turbance of  its  equilibrium  such  as  have  been  mentioned.  Certain  drugs, 
such  as  belladonna,  Avill  in  some  women  cause  a  notable  decrease  in  the 
flow  of  milk,  and  must  therefore  be  given  with  care  during  the  nursing 
period.  An  active  cathartic,  and  also  a  diet  composed  of  solid  food  and 
a  small  amount  of  water,  will  also  lessen  the  quantity  of  milk. 

Clinical  Examination  of  Human  Milk. — ^The  quality  of  the  mother's 
milk  is  of  so  much  importance  to  the  welfare  of  the  infant  that  it  is  of 
the  greatest  practical  assistance  in  the  management  of  certain  cases  to 
know  the  results  of  an  analysis  of  the  breast-milk.  This  can  be  done 
exactly  only  by  an  analytical  chemist.  The  methods  of  analysis  used 
is  too  purely  a  chemical  question  to  be  of  practical  use  in  clinical  work, 
but  simple  approximate  clinical  tests  are  often  very  desirable,  even 
though  they  are  less  accurate,  when  the  services  of  a  skilled  chemist 
cannot  be  obtained. 

To  obtain  a  specimen  for  analysis  the  hands  should  be  sterile,  the 
breast  and  nipple  should  be  carefully  washed  with  sterilized  water,  and 
from  20  to  30  c.c.  (5  to  8  drachms)  of  milk  drawn  by  the  breast-pump, 


118  PEDIATRICS. 

whirh,  being  made  of  glass,  can  also  he  thoroughly  -washed.  For  the 
analysis  either  the  entire  quantity  contained  in  the  breast  or  the  middle 
milk,  as  explained  on  page  125,  should  be  used.  The  milk  should  then  be 
poured  into  a  sterilized  bottle,  tightly  corked,  and  kept  on  ice  until  the 
examination  is  made. 

The  general  methods  of  making  the  rough  quantitative  estimation  of 
the  constituents  of  the  milk  are  as  follows:  For  the  technique  of  the  exact 
methods  of  analysis,  the  reader  is  referred  to  Bulletin  46,  revised.  United 
States  Department  of  Agricultural  Chemistry,  containing  the  methods  of 
analysis  adopted  by  the  Association  of  Official  Agricultural  Chemists, 

Specific  Gravity. — This  is  obtained  by  means  of  the  hydrometer,  for 
the  use  of  which  only  15  c.c.  (|  ounce)  of  milk  are  required. 

Fats. — In  every  case  it  is  very  important  to  know  the  exact  percentage 
of  the  fat,  both  from  its  being  the  most  variable  element  and  from  its  use 
in  the  determination  of  the  percentages  of  the  other  elements.  The  most 
exact  means  for  this  purpose  outside  of  the  chemical  laboratory  is  an 
apparatus  called  the  Babcock  Fat-Tester,  which  is  shown  in  Fig.  52,  and 
described  on  page  212.  The  smallest  amount  of  milk  required  for  deter- 
mining the  percentage  of  fat  with  the  Babcock  machine  is  17.50  c.c. 

Another  less  accurate  method  of  estimatmg  the  percentage  of  cream  is 
by  means  of  Holt's  cream-gauge. 

A  glass-stoppered  graduated  cylinder  is  filled  Avith  milk  exactly  to  the 
upper  line,  which  is  marked  0.  A  pipette  should  be  used  for  putting  the 
last  few  drops  into  the  cylinder,  care  being  taken  not  to  allow  the  milk  to 
run  down  the  inner  side  of  the  tube,  since  this  somewhat  obscures  an  exact 
reading.  The  cylinder  is  then  corked  and  allowed  to  stand  for  twenty- 
four  hours  at  a  temperature  as  near  to  21.1°  C.  (70°  F.)  as  is  practicable. 
A  variation  of  a  few  degrees  on  either  side  of  this  point  is  unimportant. 
If,  however,  the  variations  are  wide,  the  rapidity  with  which  the  cream 
prises  is  somewhat  modified.  In  the  great  majority  of  cases  the  lower  line 
of  the  cream  has  become  sharply  defined  at  the  end  of  twenty-four  hours, 
and  can  then  be  recorded.  If  this  is  not  the  case,  the  milk  should  be 
allowed  to  stand  for  six  hours  longer  before  reading  the  percentage.  By 
comparing  the  percentage  of  the  cream  Avith  that  of  the  fat,  as  determined 
by  a  chemical  analysis  of  the  same  specimen,  it  has  been  discovered  that 
the  ratio  of  the  cream  to  the  fat  is  very  nearly  5  to  3, — that  is,  5  per 
cent,  of  cream  in  the  cream-gauge  will  indicate  that  the  milk  contains  3 
per  cent,  of  fat. 

Proteids. — There  is  no  known  method  of  determining  directly  the  per- 
centage of  the  proteids  in  the  milk  by  a  clinical  examination,  and  a  com- 
plete chemical  analysis  by  an  expert  is  the  only  one  that  can  be  accepted 
as  accurate.  It  is  possible,  however,  from  a  knowledge  of  the  specific 
gravity  and  the  percentage  of  the  fat,  to  make  an  approximate  calculation 
in  regard  to  the  percentage  of  the  proteids,  at  any  rate  sufficiently  close  to 
determine  whether  in  a  given  case  they  are  near  the  normal,  or  are  in  very 


FEEDING.  119 

large  or  very  small  proportions.  Holt  has  described  a  method  in  which 
the  only  instruments  needed  are  a  small  hydrometer,  a  pipette,  and  a  glass- 
stoppered  cylinder  graduated  to  one  hundred  parts  and  holding  about  10  c.c. 

The  specimen  of  milk  for  analysis  should  be  taken  from  the  "  middle 
milk,"  and  it  is  important  that  the  milk  should  be  freshly  pumped  and 
handled  as  little  as  possible,  also  that  the  graduated  glass  cylinder  should 
be  scrupulously  clean,  otherwise  the  milk  will  often  sour  before  the  cream 
has  had  time  to  rise.  This  is  particularly  true  in  summer.  15  c.c.  (|- 
ounce)  is  the  amount  of  milk  required  for  the  test. 

In  estimating  the  proteids  certain  suppositions  must  and  can  be  fairly 
accepted : 

(1)  Supposing  the  proteids  to  remain  unaltered :  if  the  percentage  of 
fat  be  low,  the  specific  gravity  mil  be  high,  but  if  high,  the  specific  gravity 
"vvill  be  low. 

(2)  Supposing  the  fat  to  remain  unaltered :  if  the  percentage  of  the 
proteids  be  high,  the  specific  gravity  will  be  high,  but  if  the  percentage  of 
the  proteids  be  low,  the  specific  gravity  will  be  low. 

If,  therefore,  the  fat  and  the  specific  gravity  be  known,  the  proteids 
may  be  estimated  by  the  following  rules  : 

(1)  If  the  percentage  of  the  fat  be  found  to  be  high  and  the  specific 
gravity  high,  that  is,  from  1033  to  1034,  we  may  assume  that  the  proteids 
ai'e  also  of  high  percentage,  otherwise  the  excessive  fat  would  bring  the 
specific  gravity  below  the  normal  average. 

(2)  If  the  fat  be  found  to  be  of  low  percentage  and  the  specific  gravity 
high,  we  may  assume  the  proteids  to  be  nearly  normal,  since  the  high 
specific  gravity  is  explained  by  the  small  proportion  of  fat, 

(3)  If  the  percentage  of  fat  be  high  and  the  specific  gravity  low,  the 
proteids  may  be  assumed  to  be  normal,  since  the  variation  in  the  specific 
gravity  is  explained  by  the  high  percentage  of  fat. 

(4)  If  the  percentage  of  fat  be  low  and  the  specific  gravity  low,  the 
percentage  of  the  proteids  is  also  low,  since  otherwise  the  small  propor- 
tion of  fat  would  make  the  specific  gravity  above  the  averag-e. 

Of  course  it  is  only  the  wide  variations  in  the  proteids  which  can 
be  recognized  by  these  rules  ;  but  these  variations  are  often  very  impor- 
tant. 

We  can  then  say  that,  knowing  the  specific  gravity,  and  calculating  the 
fats  as  three-fifths  of  the  known  percentage  of  the  cream,  we  can  judge 
wliether  the  proteids  are  normal,  very  high,  or  very  low  in  amount. 
Whereas  only  wide  variations  can  be  recognized  by  these  rules,  even  these 
are  often  very  useful.  Holt  asserts  the  estimation  of  the  proteids  of  milk 
by  this  method  to  be  as  accurate  as  the  estimation  of  solids  by  the  specific 
gravity  in  examinations  of  the  urine. 

Sugars  and  Salts. — These  may  for  clinical  purposes  be  assumed  to 
be  about  constant  in  all  human  milk,  and  in  fact  are  practically  shown  to 
be  by  a  large  number  of  exact  chemical  analyses. 


120  PEDIATHirS. 

Microscopic  Examination. — The  mere  microscopic  examination  of  milk 
beyond  the  determination  of  the  presence  or  absence  of  colostrum  cor- 
puscles and  foreign  matters,  such  as  pus,  blood,  and  epithelial  cells,  is  too 
uncertain  and  misleading  to  be  in  any  way  depended  upon,  the  chemical 
analysis  being  the  only  practical  method  which  can  be  recommended.  The 
truth  of  this  statement  was  lately  impressed  upon  us  when  a  physician 
skilled  in  the  use  of  the  microscope  sent  me  a  specimen  of  woman's  milk 
which  he  stated  was  rich  in  fat,  but  which  the  analysis  showed  to  have 
only  a  little  over  one  and  a  half  per  cent,  of  this  element. 

The  presence  of  an  undue  amount  of  yellow  coloring  matter  is  at  times 
very  misleading.  We  have  also  seen  human  milk  which  had  a  greenish  color, 
evidently  produced  by  some  of  the  micro-organisms  which  are  known  to 
occur  in  cow's  milk,  but  the  nature  of  which  is  not  yet  fully  determined 
and  which  under  the  microscope  are  not  represented  by  anything  abnormal. 

CLINICAL  SIGNIFICANCE  OF  THE  CHEMISTRY  OF  HUMAN 
MILK. — There  is  no  doubt  of  the  great  value  of  an  expert  chemical  ex- 
amination of  the  milk  in  cases  where  an  infant  is  not  thriving,  although 
apparently  receiving  a  sufficient  quantity  of  milk  from  its  mother.  On 
the  other  hand,  we  must  remember  that  a  chemical  analysis  will  never 
give  any  information  regarding  the  cjuantity  of  the  milk,  and  it  often  hap- 
pens that  when  such  an  analysis  has  proved  the  quality  to  be  good,  the 
infant  is  not  thriving  because  the  quantity  of  the  milk  is  very  small.  The 
symptoms  which  indicate  that  it  is  the  quantity  of  milk  which  is  at  fault 
rather  than  the  quality  are  that  the  breasts  at  the  nursing  time  are  soft, 
that  only  a  small  quantity  of  milk  can  be  extracted  from  them  by  the 
breast-pump,  that  the  infant  shows  signs  of  hunger  at  the  end  of  nursing 
and  either  ceases  to  gain  or  loses  in  weight.  A  period  of  nursing  longer 
than  the  usual  fifteen  to  twenty  minutes  before  the  child  is  satisfied  should 
make  us  suspicious  that  the  milk  is  lacking  in  quantity.  "We  can  also  deter- 
-mine  the  actual  quantity  of  the  milk  which  the  child  has  imbibed  at  an 
especial  nursing  by  means  of  weighing,  as  described  on  page  58.  A  num- 
ber of  observations  at  different  nursings  in  the  day  must,  however,  be 
made  before  a  correct  conclusion  can  be  reached  by  this  latter  procedure. 

Konig,  Forster,  Meigs,  Harrington,  and  others  have  analyzed  the  milk 
of  a  large  number  of  w^omen  of  all  nationalities.  An  average  of  their 
results  is  expressed  in  the  following  table  : 

TABLE  25. 

Average  Human  Milk. 

Reaction Amphoteric. 

Specific  gravity 1028  to  1034. 

Water 87     to  88     per  cent. 

Total  solids 12     to  13     per  cent. 

Fats 3     to    4     per  cent. 

Milk-sugar 6     to    7     per  cent. 

Proteids 1     to    2     per  cent. 

Total  mineral  matter 0. 1  to    0.2  per  cent. 


FEEDING.  121 

Reaction. — According  to  Hammarsten,  woman's  milk  is  amphoteric 
in  reaction  instead  of  alkaline.  Courant  has  shown  by  delicate  chemical 
tests  that  the  relation  between  the  alkalinity  and  acidity  in  breast-milk  is 
as  3  to  1. 

Our  own  recent  investigations,  using  phenolphthalein  as  an  acid  indi- 
cator, and  lacmoid,  methyl-orange  and  cochineal  as  alkaline  indicators,  has 
also  shown  the  amphoteric  character  of  breast-milk,  the  alkalinity  of  which 
is  nearly  twice  as  great  as  the  acidity. 

Specific  Gravity. — The  specific  gravity  varies  normally  to  a  consider- 
able degree  on  account  of  the  variations  in  temperature  to  which  the 
milk  happens  to  be  exposed  at  the  time  when  the  specific  gravity  is  taken. 
When,  however,  the  milk  has  its  average  normal  composition,  and  the 
temperature  to  which  it  is  exposed  is  15.5°  C.  (60°  F.),  its  average  spe- 
cific gravity  is  1031. 

"Water. — One  of  the  most  important  chemical  facts  to  be  remembered 
for  clinical  purposes  is  the  very  large  proportion  of  water  which  is  found 
in  normal  human  milk,  for  it  shows  it  to  be  a  highly  diluted  food  by  which 
the  best  results  can  be  obtained  in  infant  feeding.  It  also  indicates  the 
care  that  should  be  taken  not  to  overtax  the  comparatively  slight  power 
of  absorbing  a  concentrated  food  which  exists  in  the  early  months  of  life. 

Fat. — The  fat  of  human  milk  is  made  up  chiefly  of  palmitin,  stearin, 
and  olein.  About  two  per  cent,  of  the  total  fat  consists  of  the  glycerides 
of  butyric,  caproic,  caprylic,  and  myristic  acids.  Butyric,  caproic,  caprylic 
and  capric  acids  are  present  in  smaller  proportions  in  human  milk  than  in 
cow's  milk,  which  accounts  in  part  for  the  greater  digestibility  of  the  fat  of 
breast-milk  as  compared  with  that  of  cow's  milk.  The  production  of 
animal  heat  is  so  very  important  a  part  of  the  infant's  well-being  that  it  is 
not  surprising  we  should  find  so  large  a  percentage  of  fat  as  Avell  as  of 
sugar  in  the  food  which  is  provided  for  it.  The  presence  of  fat  in  the  milk 
is  not  only  for  the  purpose  of  nutrition,  but  also  as  a  means  for  the  main- 
tenance of  bodily  heat.  This  latter  function  of  the  fat  cannot  with  impunity 
be  trifled  with,  and  is  essential  for  active  metabolism.  A  proper  amount 
of  fat  is  probably  of  great  aid  in  the  regulation  of  the  faecal  discharges.  An 
amount  of  fat  proportionate  to  the  proteids  is  presumably  necessary,  or  at 
least  of  great  aid,  in  their  proper  digestion.  We  should  naturally  expect 
that  unless  the  standard  percentage  of  fat,  or  at  least  a  near  approach  to  it, 
existed  in  the  mother's  milk,  trouble  would  be  likely  to  arise  with  her  in- 
fant, and  this  corresponds  with  our  experience  in  cases  in  which  the  special 
ingredient  which  has  interfered  with  the  success  of  the  nursing  has  been 
the  fat.  We  have  found  clinically  that  when  the  fat  was  much  lessened 
the  nutrition  suffered,  that  the  digestion  was  not  good,  and  that  there  was 
a  tendency  to  constipation,  while  when  its  percentage  was  decidedly  above 
the  standard  the  digestion  was  weakened,  there  was  a  tendency  to  diar- 
rhoea, and  in  consequence  a  resulting  poor  nutrition. 

These  clinical  observations  at  once  suggest  that  in  the  ijianagement 


122  PEDIATRICS. 

of  infant  feeding  we  must  recognize  the  existence  of  two  important  con- 
ditions.    One  of  these  is  the  digestion  of  the  infant,  the  other  is  its  nutri- 
tion.    These  two  requirements  for  a  successful  lactation  are  based  on  the 
facts  that  the  milk  may  be  easily  digested  but  not  nutritious,  and  that  it 
may  be  higlily  nutritious  but  difficult  to  digest,  so  that  it  is  the  ec|uilibrium 
of  these  two  conditions  which  produces  a  perfect  infantile  development. 
It  is  especially  important  that  the  percentage  of  fat  in  an  infant's  food 
should  be  within  the  hmits  of  the  normal  variations  which  are  found  in 
the  milk  of  healthy  nursing  women  with  healthy  infants.     For,  although 
it  is  admitted  that  a  large  percentage  of  surplus  fat  is  frequently  found  in 
the  ffeces  of  infants  w^hose  digestion  and  nutrition  are  normal,  and  whose 
food  is  human  milk,  yet  we  have  no  more  right  to  conclude  from  this  that 
a  small  percentage  of  fat  is  sufficient  for  nutrition,  or  that  a  large  surplus 
will  be  eliminated  by  the  fseces,  than  we  have  to  assume  that  there  is  too 
much  oxygen  in  the  blood  because  w^e  find  a  certain  surplus  of  oxygen  in 
the  blood  which  is  returned  to  the  lungs  in  the  venous  circulation.     In 
fact,  it  is  far  more  probable  that  nature  introduces  a  certain  percentage 
of  fat  into  human  milk  with  a  purpose  w^hich  can  be  accomplished  only 
by  that  percentage,  so  that  it  is  an  error  to  change  this  percentage  beyond 
the  variation  wdiich  commonly  occurs  in  average  human  milk. 

Sugar. — The  form  of  sugar  which  is  found  in  human  milk  is  called 
milk-sugar,  or  lactose,  and  has  the  highest  percentage  of  all  the  elements 
constituting  the  total  solids  of  the  milk.  The  sugar  is  more  digestible  than 
the  fat,  but  does  not  have  so  much  potential  energy — that  is,  so  much 
heat-producmg  power  in  a  given  weight — as  does  the  fat,  wdiich  is  to  the 
sugar  as  2.4  to  1.  The  partial  conversion  of  milk-sugar  into  lactic  acid 
gives  rise  to  many  of  the  changes  occurring  in  milk. 

Proteids. — Although  there  have  been  a  great  many  different  opinions 
expressed  as  to  the  average  percentage  of  the  total  proteids  in  liuman 
_milk,  we  are  led  at  present  to  believe  that  it  is  normally  one  or  two  per 
cent.  Proteid  is  a  general  name  including  caseinogen  and  lactalbumin, 
which  in  its  general  features  resembles  ordinary  serum-albumin,  but  the 
ultimate  chemistry  of  these  elements  is  still  obscure.  We  recognize  that 
this  lactalbumin  is  present  in  small  and  variable  quantities  when  the 
mammary  gland  and  its  secretion  are  in  a  normal  condition,  while  at  the 
time  when  the  glandular  function  is  being  established,  and  during  periods 
of  glandular  disturbance,  it  becomes  proportionately  larger  in  amount. 
According  to  Konig,  who,  in  his  comparative  analysis  of  the  caseinogen 
and  lactalbumin  in  human  milk,  estimates  the  total  proteids  at  1.82,  the 
caseinogen  has  a  percentage  of  0.59,  w-hile  the  lactalbumin  is  1.23,  and 
other  analyses  show  a  greater  proportion  of  caseinogen  than  this.  The 
proteids,  as  a  whole,  are  a  valuable  source  of  information  to  us  when  we 
are  determining  whether  the  milk  is  normal  or  abnormal,  and  in  arranging 
an  infant's  food  the  relative  proportions  of  the  caseinogen  and  lactalbumin 
should  be  borne  in  mind. 


FEEDING.  123 

Mineral  Matter. — The  mineral  matter,  which  is  sometimes  called  the 
ash  and  sometimes  the  salts,  has  an  average  percentage  of  from  0.1  to  0.2. 
Up  to  the  present  time,  although  a  certain  number  of  analyses  of  the  min- 
eral matter  of  human  milk  have  been  made,  yet  the  results,  for  various 
reasons,  have  been  deemed  unsatisfactory.  So  large  a  quantity  of  milk  is 
needed  for  a  reliable  determination  of  the  percentage  of  each  element 
which  makes  up  the  total  amount,  that  this  in  itself  has  been  an  important 
reason  for  failure  in  accuracy.  The  determination  of  the  mineral  matter 
of  cow's  milk  has  not  been  attended  with  the  same  difficulty,  and  its  per- 
centages have  been  estimated  with  comparatively  reliable  results.  It  has 
always  been  supposed  that  there  is  a  radical  difference  between  the  per- 
centages of  the  mineral  matter  of  cow's  milk  and  that  of  human  milk.  The 
exact  knowledge  of  the  percentages  which  exist  in  the  latter  has  become 
of  still  greater  importance  since  such  decided  advances  have  been  made  in 
the  modification  of  the  elements  of  the  former.  With  the  view  of  making 
some  advance  in  this  difficult  question,  and  of  providing  for  the  milk- 
modifiers  of  the  future  a  more  exact  basis  for  perfecting  a  substitute  food 
resembling  as  closely  as  possible  the  product  of  the  human  breast,  we  un- 
dertook, in  the  spring  of  1893,  to  procure  an  unusual  and  sufficient 
quantity  of  human  milk  for  analytical  purposes.  In  the  course  of  a  few 
weeks,  by  means  of  the  concerted  action  of  numerous  assistants,  we  col- 
lected five  and  a  half  liters  (about  six  quarts)  of  human  milk,  which  is  an 
unusually  large  quantity  for  experimental  purposes.  This  milk  was  im- 
mediately reduced  to  its  mineral  constituents  in  the  laboratory  of  Dr. 
Charles  Harrington.  The  analysis  of  this  large  amount  of  mineral  matter 
was  then  made  by  Dr.  Harrington  and  Dr.  L.  P.  Kinnicutt,  with  the  follow- 
ing results : 

Tlie  Mineral  Matter  of  Human  Milk. 

Unconsumed  carbon 0.71 

Chlorine 20.11 

Sulphur 2.19 

Phosphoric  acid 10. 73 

Silica 0. 70 

Carbonic  acid 7.97 

Iron  oxide  and  alumina 0.40 

Lime 15.69 

Magnesia 1.92 

Potassium 24.77 

Sodium 9.19 

Oxygen   (calculated ) 6.16 

100.54 
In  considering  this  analysis  one  should  bear  in  mind  that  in  woman's 
milk  naturally  there  would  be  no  free  carbon,  the  calcium  that  did  not 
exist  as  phosphate  would  be  in  the  form  of  sulphate  and  carbonate,  not 
of  sulphite  and  oxide,  the  magnesium  would  exist  as  carbonate,  not  as 
oxide,  and  the  potassium  as  sulphate,  carbonate  or  chloride,  and  no  sul- 
phate of  potassium  would  be  present.  These  differences  are  due  to  the 
ignition  of  the  ash  in  the  process  of  evaporation. 


124  PEDIATRICS. 

Composition  of  the  Mineral  Matter  calculated jrom  the  abuoe  Analysis. 

Uncombined  carbon 0. 71 

Calcium  phosphate 25.35 

Calcium  silicate 1.35 

Calcium  sulphite 2.11 

Calciimi  oxide 1. 72 

Magnesium  oxide 1.91 

Potassium  carbonate 24. 93 

Potassium  sulphite 8.04 

Potassiuni  chloride 12.80 

Sodium  chloride 23.13 

Iron  oxide  and  alumina 0.40 

102.45 

A  closer  approximation  to  the  relative  proportions  of  the  salts  in  the 
form  in  which  they  occur  in  milk,  calculated  from  the  above  analysis,  may 
be  stated  as  follows  : 

Calcium  phosphate 28.87 

Calcium  silicate 1.27 

Calcium  sulphate 2.25 

Calcium  carbonate 2. 85 

Magnesium  carbonate 3.77 

Potassium  carbonate 23.47 

Potassium  sulphate 8.33 

Potassium  chloride 12.05 

Sodium  chloride 21.77 

Iron  oxide  and  alumina 0.37 

100.00 


In  comparing  the  previous  analyses  whicli  have  been  made,  and  which 
can  be  found  in  Konig's  Nahrungsmittel,  11. ,  2°  Auflage,  with  this  new 
analysis,  we  must  remember  that  the  previous  analyses  were  made  some 
years  ago.  In  the  last  few  years  the  processes  which  have  been  employed 
have  been  so  much  more  exact  that  these  results  must  be  considered  far 
more  trustworthy  than  those  made  at  an  earlier  date.  It  is  not  remark- 
able, therefore,  that  distinct  diiferences  should  be  found  between  this 
new  analysis  and  the  analyses  .which  have  hitlierto  been  made,  and  pre- 
sumably this  last  analysis  is  the  correct  one.  It  has  been  made  with 
tlie  greatest  care,  and  by  means  of  the  most  improved  technique,  by  two 
eminently  competent  and  well-knoAvn  chemists,  who  in  their  work  have 
acted  as  controls  on  each  other.  In  this  way  great  precision  has  been 
attained. 

The  chief  differences  between  this  new  analysis  and  all  previous  ones 
are  as  follows : 

(1)  The  phosphoric  acid  is  less  than  half  as  much  as  previously  re- 
ported. 

(2)  The  magnesium  is  also  less  than  half  as  much. 

(3)  Silica  and  alumina  are  present.  They  have  not  been  returned  in 
any  previous  analysis. 


FEEDING.  125 

Assuming  the  truth  of  the  statement  that  the  constituents  of  the 
mineral  elements  of  human  milk  are  subject  to  great  fluctuation  according 
to  age  and  other  causes,  it  is  right  to  assume  that  the  mineral  matter  ex- 
amined by  Harrington  and  Kinnicutt,  being  the  product  of  a  large  number 
of  women,  is  a  fair  average  specimen. 

Variations  in  Milk. — We  are  led  to  expect  that  we  shall  find  that 
when  the  milk  is  poor  and  does  not  agree  with  the  infant  there  is  an 
excess  of  proteids  and  a  diminution  of  fat  beyond  what  Ave  have  so  far 
been  able  to  determine  as  the  normal  average  percentages  of  these  two 
elements.  Again,  Avhen  a  variation  takes  place  in  the  milk  it  is  more 
likely  to  be  found  in  the  fat  and  proteids,  as  already  stated,  than  in  the 
sugar  or  the  mineral  matter.  It  is  also  important  to  have  a"  number  of 
analyses  made,  on  different  days  and  at  different  times,  in  order  that  the 
error  of  an  especial  or  temporary  variation  may  be  corrected.  The  im- 
portance of  the  assistance  which  can  be  gamed  from  these  analyses  is,  in 
our  opinion,  very  great,  and  many  more  analyses  should  be  made  than  we 
are  now  in  the  habit  of  deeming  necessary.  The  question  of  expense 
should  not  for  a  moment  be  considered  by  those  who  can  afford  to  have 
analyses  made,  for  not  only  will  real  benefit  come  to  their  own  children 
through  money  spent  in  this  way,  but  these  analyses,  when  published  and 
collated,  Avill  prove  of  great  value  for  the  proper  regulation  of  the  feeding 
of  infants  in  all  classes  of  society.  An  error  for  which  we  must  always 
allow  may  interfere  with  the  true  analysis  of  the  milk  which  the  infant 
has  actually  received  in  its  stomach  at  the  end  of  the  nursing,  and  is  one 
which  must  necessarily  invalidate  the  information  Avhich  we  receive  from 
our  analysis.  This  subject  has  already  been  referred  to  in  speaking  of 
the  changes  which  arise  from  slight  causes  and  influence  the  special 
specimen  Avhich  is  being  analyzed.  Thus,  we  should  recognize  that  the 
milk  varies  considerably  in  its  percentage  of  fat  and  total  solids  in  the 
different  periods  of  a  nursing,  and  that  the  composition  of  the  milk  which 
the  infant  has  in  its  stomach  may  differ  very  widely  from  the  composition 
of  a  specimen  taken  directly  before  or  after  the  nursing.  Harrington's 
analyses  of  the  three  periods  of  a  milking  Avill  illustrate  the  meaning  of 
what  has  j  ust  been  said,  and  although  they  were  made  from  the  milk  of  a 
cow,  yet  knowing  the  closely  analogous  conditions  existing  in  human  and 
in  animal  milk,  we  shall  find  them  ecfually  valuable  in  explaining  the 
corresponding  changes  met  with  in  woman's  milk.  They  are  represented 
in  this  table  (Table  26) : 

TABLE  26. 

Fat.       Total  Solids.  Water.  Mineral  Matter. 

"Fore-milk" 3.88            13.34  86.66            0.85 

"Middle  milk" 6.74           15.40  84.60           0.81 

"Strippings" 8.12           17.13  82.87           0.82 

Reiset  and  Peligot  have  also  made  analyses  of  the  first,  second,  and 
Ihird  portions  of  ass's  and  cow's  milk,  with  the  result  of  showing  not 


12G  PEDIATRICS. 

only  the  increase  of  solids  at  the  end  of  a  milking,  but  also  tliat  this  in- 
crease is  mostly  of  the  fat,  and  to  a  lesser  degree  of  the  proteids,  and  that 
a  short  interval  of  nursing  increases  tlie  solid  constituents  in  proportion 
to  the  water,  the  reverse  of  tills  being  true  when  the  intervals  are  long. 
Heidenhain  explains  this  physiological  phenomenon  by  saying  that  his  in- 
vestigations point  towards  the  fact  that  during  tlie  pauses  between  the 
milkings  the  cells  of  the  glands  are  growing.  During  this  time  a  propor- 
tionately small  amount  of  solids  and  a  proportionately  large  amount  of 
water  are  secreted,  while  the  irritation  of  milking  causes  increased  activity 
of  the  milk-cells,  with  a  corresponding  increase  in  the  solid  secretion  and 
a  lessening  of  the  water. 

Harrington's  analyses  of  woman's  milk  showing  the  "  strippings"  of 
a  two-hours  interval  and  the  "  fore-milk"  of  a  twelve-hours  interval  are 
also  of  considerable  interest : 

"  strippings,"  '  Fore-Millc." 

2-hours  Interval.  12-hours  Interval. 

Total  solids 15.32  10.14 

Water 84.68  89.86 

100.00  100.00 

Reasoning  from  the  strong  analogy  which  must  exist  between  human 
milk  and  cow's  milk,  and  being  aware  of  the  great  variations  which  occur 
in  the  latter,  we  may  assume  that  human  milk  is  liable  to  vary  in  its  com- 
position considerably  with  different  milkings  on  the  same  day,  and  also  with 
the  milkings  of  the  same  hours  on  different  days,  so  that  at  present  we  are 
not  in  a  position  to  state  that  our  knowledge  of  human  milk  is  sufficiently 
exact  to  justify  an  attempt  to  formulate  a  table  to  show  the  composition  of 
woman's  milk  at  different  periods  of  her  lactation,  however  valuable  such 
information  may  in  the  future  prove  to  be.  We  must  also  understand  that 
human  milk  of  normal  quality,  and  proving  to  be  equally  nutritious  to  the 
special  infants  that  are  fed  on  it,  may  vary  considerably  in  the  percentages 
of  all  its  elements,  and  in  the  combinations  of  these  percentages.  This  fact 
is  well  illustrated  in  the  following  table,  showing  the  analyses  of  fourteen 
specimens  of  human  milk  all  differing  in  the  combinations  of  their  dif- 
ferent elements : 

TABLE  27.      (Harrington.) 

Huma7i  Breast-Milk  Anahjscs. 

[Mothers  healthy,  and  infants  all  digesting  well  and  gaining  in  loeight. ) 

I.                   11.                 III.               IV.                 v.                 VI.  VII. 

•    I'er  Cent.  Pur  Cent.  Per  Cent.  Per  Cent.  Per  Cent.  Per  Cent.  Per  Cent 

Fat 5.16           4.88           4.84           4.37           4.11           .^,.82  3.80 

Milk-sugar 5.68           6.20           6.10           6.30           5.90           5.70  6.15 

Proteids 4.14           3.71           4.17           3.27           3.71           1.08  3.53 

Mineral  matter  .        0.17           0.19           0.19           0.16           0.21           0.20  0.20 

Total  solids.    ...     15.15         14.98         15.30  14.10         13.93  10.80  13.68 

Water 84.85  85.02         84.70  85.90        86.07  89.20  86.32 

100.00  100.00  100.00  100.00  100.00  loo.  00  100.00 


VIII. 

1 
IX. 

FEEDING 

X. 

XI. 

XII. 

XIII. 

12 

XIY. 

Per  Cent. 

.  Per  Cent. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

Per  Cent. 

Fat 

3.76 

3.30 

3.16 

2.96 

2.36 

2.09 

2.02 

Milk-sugar  .  .  .  . . 

6.95 

7.30 

7.20 

5.78 

7.10 

6.70 

6. 55 

Proteids  

2.04 

3.07 

1.65 

1.91 

2.. 20 

1.38 

2.12 

Mineral  matter 

0.14 

0.12 

0.21 

0.12 

0.16 

0.15 

0.15 

Total  solids 

.      12.89 

13.79 

12.22 

10.77 

11.82 

10.32 

10.84 

Water 

87.11 

86.21 

87.78 

89.23 
100.00 

88.18 

89.68 

89.16 

100.00 

100.00 

100.00 

100.00 

100.00 

100.00 

All  these  specimens  of  milk  were  obtained  from  healthy  mothers,  and 
in  every  case  the  infant  was  thriving.  In  a  number  of  these  cases,  how- 
ever, when  one  of  the  infants  which  was  doing  well  on  its  own  mother's 
milk  was  fed  AA-ith  one  of  the  other  combinations,  it  soon  became  sick,  and 
had  to  be  changed  back  to  the  one  adapted  to  its  digestion.  Human  milk 
may.  then,  be  considered  to  represent  not  an  especial  food  but  a  combina- 
tion of  foods,  and  its  fat,  sugar,  proteids,  and  mineral  matter  to  represent 
these  different  foods.  In  other  words,  we  find  by  experience  that  the 
digestive  capabilities  of  infants  differ,  just  as  do  those  of  adults,  and  that 
nature  provides  a  number  of  varieties  of  good  human  milk  adapted  to  the 
varying  idiosyncrasies  of  infants. 

We  should  also  conclude  from  the  above  figures  that  as  the  standard 
of  the  breast-milk  must  be  determined  by  the  effect  of  the  milk  on  the 
digestion  and  nutrition  of  the  infant,  a  chemical  examination  without  the 
clinical  history  may  lead  to  erroneous  conclusions  as  to  the  quality  of  the 
food  in  any  given  case. 

BACTERIOLOGICAL  EXAMINATION.— Although  human  milk  is 
usually  considered  to  be  sterile,  except  in  some  cases  in  which  the  woman 
is  diseased,  yet  Cohn  and  Neumann  have  examined  the  milk  of  forty-eight 
healthy  women  and  have  found  bacteria  in  forty-three  cases.  These  or- 
ganisms were  mostly  represented  by  the  staphylococcus  pyogenes  albus, 
with  a  few  of  the  staphylococcus  pyogenes  aureus  and  the  streptococcus 
pyogenes.  They  found  fewer  bacteria  when  the  breast  had  been  emptied 
a  short  time  previously,  and  more  when  there  had  been  a  stagnation  of 
the  milk  in  the  breast.  More  bacteria  were  also  found  in  the  first  few 
drops  than  in  the  last  ones,  and  from  their  experiments  they  concluded 
that  the  bacteria  enter  the  nipple  from  Avithout.  The  conclusions  deduced 
from  their  experiments,  as  well  as  from  the  experiments  of  others  who 
have  met  with  similar  results,  seem  to  show  practically  that  bacteria  can 
enter  the  ducts  of  the  nipple  and  penetrate  to  a  greater  or  less  distance  ; 
also  that  the  milk  in  its  course  from  the  gland  to  the  nipple  washes  out 
the  bacteria,  and  that  we  can  in  this  way  account  for  the  presence  of  these 
organisms  in  the  milk  wiiich  is  first  drawn  from  the  breast,  and  their 
absence  from  that  which  comes  later. 

MANAGEMENT  OP  POOD  IN  EARLY  DAYS  OP  LIPE.— 
Young  animals  at  birth  begin  to  receive  their  nourishment  immediately, 
and  a  corresponding  increase  in  their  weight  takes  place  from  the  first  day 


128  PEDIATRICS. 

of  life.  The  human  hifant  in  like  manner  should  begin  with  its  nursing 
early,  getting  what  it  can  from  the  breast  until  the  full  supply  of  milk  has 
come.  In  this  way  it  will  not  be  so  likely  to  have  a  large  initial  loss  of 
weight  to  regain,  a  condition  by  which  it  is  often  handicapped  at  the  very 
beginning  of  its  career,  when  there  is  most  danger  to  be  apprehended  from 
a  depression  of  its  vitality.  Every  day,  every  hour,  is  of  the  utmost  im- 
portance in  the  early  days  of  life,  and  provided  it  can  be  done  A^ithout 
detriment  to  the  condition  of  the  mother,  the  sooner  the  infant  is  put  to 
the  breast  the  better  it  will  be.  During  the  first  twelve  hours  of  life,  and 
in  most  cases  during  the  first  twenty-four  to  thirty-six  hours,  owing  to  the 
inability  of  the  mother  to  supply  milk  for  her  infant,  scarcely  any  food  is, 
as  a  rule,  obtained.  If  during  this  period  the  infant  is  restless  and  evi- 
dently hungry,  5  to  10  c.c.  (1  to  2  drachms)  of  a  sugar  solution  may  be 
given  at  intervals  of  two  or  three  hours.  This  solution  should  be  made 
by  dissohing  milk-sugar  in  sterilized  water,  and  its  strength  sliould  be 
from  five  to  six  per  cent.  If  the  mother's  milk  is  delayed  still  longer, 
something  additional  must  be  given  to  the  infant,  and  in  these  cases  the 
following  prescription  is  useful : 

Prescription  2. 

Fat 1.50  to  2.00 

Sugar 5.00 

Proteids (AVhey-Proteids.  0.25  ;  Caseinogen,  0.25)  0.50 

Eeaction  slightly  alkaline. 
10  feedings,  each  30  c.c.  (1  ounce) .  To  be  heated  for  thirty  minutes  at  75°  C.  (167°  F.) 

Intervals  of  Feeding. — The  younger  the  infant  the  greater  the  meta- 
bolic activity,  and  hence  the  greater  need  of  frequent  feeding,  for  food  is 
required  not  only  for  repair  of  waste,  but  also  for  the  infant's  rapid  pro- 
portionate growth.  This,  with  the  increased  demand  for  additional  animal 
heat,  makes  essential  the  regulation  of  the  intervals  of  feeding  according 
to  the  age. 

The  intervals  constitute  a  very  important  part  of  tlie  management  of 
breast  feeding,  when  the  quantity  is  regulated  by  the  breast  itself.  These 
intervals  should  be  definitely  stated  to  the  mother  at  different  times 
throughout  the  nursing  period,  and  should  be  adhered  to.  The  following 
table  represents  the  intervals  for  an  average  breast-fed  infant,  but  it  should 
be  understood  that  the  intervals  of  feeding  should  be  made  to  correspond 
to  the  stage  of  development  of  the  individual : 

TABLE  28. 
TViii  day  feedings  are  supijosed  to  heghi  at  6  A.  M.  and  to  e)id  at  10  P.  M. 


Number  Of 

Number  of 

Age. 

Intervals. 

Feedings  in 
24  hours. 

Night  Feedings. 

From  birth  to  4  weeks     . . . . 

....  2  hours 

10 

1 

"            4  to    8      " 

...  2A    "     ...:.. 

8 

1 

"            2  to    4  months  .  . . . 

2i     " 

/ 

0 

"            4  to  10       " 

.3      "     

6 

0 

"          10  to  12 

....3      "     

5 

0 

FEEDIXG.  229 

When  the  milk  has  begun  to  be  produced  in  the  breast,  the  infant 
should  be  fed  once  in  two  hours  during  the  day  and  once  during  the  night 
until  it  is  six  weeks  old.  The  day  feedings  are  usually  reckoned  from  6 
A.M.  to  10  P.M.  The  time  for  the  night  feeding  usually  found  to  be  most 
convenient  is  2  a.m.  This  interval  of  two  hours  should  be  adhered  to, 
allowing  that  exceptional  circumstances  may  arise  in  which  the  physician 
must  judge  according  to  the  individual  case,  until  the  sixth  or  eighth  week 
is  reached,  when  the  intervals  may  be  made  two  and  one-half  hours,  and 
the  number  of  feedings  in  the  twenty-four  hours  eight.  At  about  the 
fourth  month  the  intervals  can  be  made  three  hours,  and  the  number  of 
feedings  six.  When  the  infant  is  two  or  three  months  old,  the  night  feed- 
ing can  be  omitted.  The  number  of  feedings  at  ten  months  may  be 
reduced  to  five.  Allowing  the  mother  to  have  as  many  hours  of  continu- 
ous sleep  at  night  as  possible  is  especially  important,  in  order  that  she  may 
not  be  exhausted  by  the  lack  of  that  regular  and  sufficient  rest  which  is  of 
the  utmost  necessity  for  the  production  of  a  normal  milk. 

Irregularity  in  nursing,  too  frequent  nursing,  and  too  prolonged  inter- 
vals often  so  disturb  the  quality  of  human  milk  as  to  transform  a  perfectly 
good  milk  into  one  entirely  unfitted  for  the  infant's  powers  of  digestion. 
Thus,  too  frequent  nursing  lessens  the  water  and  increases  the  total  solids 
in  human  milk,  making  it  resemble  in  a  certain  way  condensed  milk ; 
while  too  prolonged  intervals  result  in  such  a  decrease  of  the  total  solids 
as  to  render  an  otherwise  good  milk  too  watery  and  unfit  for  purposes 
of  nutrition,  however  well  it  may  be  digested.  The  lesson  that  may  be 
drawn  from  these  facts  is  that  some  general  rules  for  the  feeding  intervals 
should  not  only  be  recommended  but  enforced.  The  mother  should 
neither  injure  her  infant's  digestion  by  nursing  it  too  frequently,  and  thus 
giving  it  a  too  concentrated  fluid,  nor,  by  neglecting  to  feed  it  often  enough, 
interfere  with  its  nutrition  by  giving  it  a  food  that  is  too  diluted. 

Evidences  of  Normal  Lactation. — In  judging  of  the  results  of  breast 
feeding  in  any  given  case,  we  must  fully  appreciate  the  fact  that  it  is  the 
equilibrium  between  the  digestion  and  nutrition  which  constitutes  success. 
A  child  may  digest  its  milk  perfectly  and  yet  drop  steadily  behind  in  its 
weight  development.  On  the  other  hand,  it  may  make  satisfactory  gains  in 
weight  from  week  to  week,  in  spite  of  persistent  symptoms  of  gastric  and 
intestinal  indigestion.  In  either  case  the  indications  for  regulation  of  the 
feeding  are  present. 

It  is  desirable,  both  in  breast  and  substitute  feeding,  to  keep  careful 
records  of  the  state  of  the  digestion,  and  of  the  weekly  gains  in  weight.  A 
child  in  whom  the  equilibrium  between  digestion  and  assimilation  is  well 
established  shows  the  unmistakable  signs  of  good  health.  It  is  free  from 
vomiting  and  colic.  Its  sleep  is  restful  and  regular.  It  is  always  eag'er  to 
nurse  and  satisfied  at  the  end  of  the  prescribed  period  of  fifteen  or  twenty 
minutes.  It  cries  only  when  disturbed  by  urination,  defecation  or  hunger 
shortly  before  nursing.     The  movements  are  regular,  one  or  two  a  day, 

9 


130  PEDIATRICS. 

smooth,  of  a  light  yellow  color  and  mush-like  consistency  and  slight  faecal, 
but  not  foul  or  sour  odor.  Its  weekly  gain  in  weight  is  regular  but  varies 
greatly,  according  to  individual  peculiarity.  The  importance  of  weight 
development  as  an  indication  of  the  nutrition  of  the  infant  is  very  great 
and  furnishes  us,  both  in  breast  and  substitute  feeding,  wdth  the  most  valu- 
able evidence  of  all  as  to  the  success  of  the  feeding  in  any  particular  case, 
or  as  to  the  necessity  of  instituting  some  change.   See  p.  — . 

Regimen  of  Lactation.     Diet. — The  diet  of  the  nursing  mother  should 
not  essentially  differ  from  what  would  be  considered  to  be  a  healthy  one 
for  her  at  any  time.     There  is  no  special  diet  which,  under  all  circum- 
stances, is  best  for  all  nursing  women  during  the  period  of  their  lacta- 
tion.    In  the  early  days   of  the  puerperium  there  is,  as  a  rule,  more 
danger  of  overfeeding  than  of  underfeeding  the  mother.     The  tendency 
is  to  give  too  much  meat  and  solid  food,  with  the  result  that  when  the 
secretion  of  the  milk  is  being  established  the  total  solids  are  increased 
to  a  degree  beyond  the  capacity  of  the  still  undeveloped  digestive  function 
of  the  infant.     Infants  in  the  early  days  and  weeks  of  life  thrive  better 
on  a  milk  that  shows  a  high  percentage  of  water  in  proportion  to  that  of 
the  total  solids.    A  rule  which  has  in  our  experience  become  almost  an 
axiom  is  that  the  age  of  the  individual  infant  is  in  inverse  proportion  to 
its  powers  of  absorbing  solid  food,  and  in  direct  proportion  to  the  need 
of  a  large  amount  of  water  in  its  food.     A  light  and  plentiful  diet  should 
therefore  be  given  to  the  mother  while  she  is  confined  to  her  bed.     This 
diet  should  consist  of  milk,  gruels,  soups,  vegetables,  bread  and  butter, 
and  after  the  first  week  a  small  amount  of  meat  once  during  the  twenty- 
four  hours.     When  the  mother  is  able  to  go  out  of  the  house  again,  and 
has  resumed  her  usual  habits,  the  quality  of  the  diet  can  be  very  much 
increased,  and  she  can  have  the  usual  variety  of  food   represented  by 
meats,  vegetables,  milk,  fruits,  and  cereals.     There  are  no  special  kinds 
of  food  which  are   contra-indicated,  provided  we  keep  the  food  within 
-the  limits  of  the  ordinary  articles  which  commonly  represent  a  plain  but 
nutritious  diet.     It  is  very  important  for  the  nursing  mother  to  have  her 
meals  at  regular  intervals,  and  during  the  early  part  of  the  lactation  to 
take  food  somewhat  more  frequently  than  when  she  is  not  nursing.     The 
additional  meals,  as  a  rule,  should  be  made  up  of  milk  or  cocoa.     There 
does  not  seem  to  be  any  advantage  in  adding  any  special  beverages,  SQch 
as  beer,  malt,  or  stimulants,  to  her  diet.    She  should  receive  as  much  milk 
as  is  compatible  with  her  digestion,  and  should  drink  a  plentiful  supply 
before  retiring  at  night.     This  wide  range  of  food  for  the  nursing  mother 
has  been  recommended  with  a  purpose.     The  food  of  the  nursing  woman 
is  without  doubt  closely  connected  ^^'iih.  that  which  she  provides  for  her 
infant.    Various  substances  are  eliminated  by  the  mammary  gland,  and  we 
should  therefore  impress   upon   mothers  the  importance   of  a  carefully 
arranged  diet  when  they  are  nursing.     Certain  vegetables,  and  sometimes 
fish,  will  in  individual  cases  affect  the  milk  and  cause  discomfort  to  the 


FEEDING. 


131 


infant.  We  must,  then,  in  every  case,  seek  to  determine  wliich  article  of 
diet  may  cause  disturbance  in  the  special  woman's  milk  secretion,  and 
eliminate  that  article.  We  should,  however,  be  very  careful  not  to  prohibit 
this  special  .article  of  diet  from  the  regimen  of  a  large  number  of  v/omen  to 
whom  it  might  be  of  benefit  rather  than  of  harm,  simply  because  it  has 
affected  the  milk  of  a  few  women.  For  the  average  woman  a  plain  mixed 
diet,  mth  a  moderate  excess  of  fluids  and  proteids  over  what  she  is  nor- 
mally accustomed  to,  will,  as  a  rule,  give  the  best  results. 

Exercise. — Exercise  has  so  constant  an  influence  on  the  changes  which 
take  place  in  the  daily  secretion  of  the  milk,  that  the  mother  should  be 
encouraged  to  be  out  of  bed  and  to  walk  about  her  room  as  soon  after 
her  confinement  as  is  possible  without  injuring  her  physical  condition. 
Exercise  is  so  important  for  promoting  the  proper  elaboration  and  equi- 
librium of  the  milk  secretion  during  the  entire  period  of  lactation,  that  it 
should  always  be  insisted  upon,  and  regular  hours  for  walking  should  be 
as  definitely  arranged  during  the  day  as  the  hours  for  eating.  The  exer- 
cise must,  however,  be  in  accordance  with  the  strength  of  the  special 
woman,  for  fatigue  has  the  same  deleterious  influence  on  the  production 
•of  the  milk  as  has  lack  of  exercise. 

DISTURBED  LACTATION. — The  disturbances  which  are  liable  to 
occur  in  the  course  of  lactation  are  frequent  and  varied.  They  should  be 
studied  carefully  and  recognized  at  once  Avhen  they  occur,  or  the  continu- 
ation of  the  lactation  may  not  only  be  interfered  with  but  be  prevented 
entirely.  When  colostrum  corpuscles  are  found  after  the  first  two  weeks 
of  life  the  milk  should  be  looked  upon  with  distrust,  and  special  efforts 
should  be  made  to  discover  the  reason  of  their  persistence,  and  to  prevent 
the  dangers  which  are  liable  under  these  circumstances  to  arise.  These 
dangers  may  be  not  only  from  combinations  of  the  milk  elements  which 
are  incompatible  with  the  infant's  digestion,  but  also  from  the  disturbances 
which  may  arise  from  the  free  mammary  elimination  of  foreign  material. 

Drugs. — We  know  that  during  periods  of  mammary  disturbance  there 
is  a  much  greater  possDDility,  than  when  the  gland  is  in  a  normal  condition, 
of  the  direct  transudation  from  the  blood  of  such  inorganic  substances  as 
arsenic,  antimony,  lead,  iodide  of  potash,  mercury,  and  others,  taken  by  the 
mother.  Well-authenticated  cases  come  to  our  notice  from  time  to  time 
in  which  injury  has  been  done  to  the  nursing  infant  in  this  way,  and  in 
which  even  death  has  occurred  from  the  elimination  by  the  breast-milk 
of  certain  organic  substances,  such  as  colchicum  and  morphine. 

The  greatest  variety  of  substances  have  been  found  in  the  milk,  but  no 
definite  rule  as  to  the  amount  of  this  elimination  has  yet  been  established, 
so  that  our  knowledge  of  the  existence  of  this  process  is  valuable  as  a 
prophylactic  agamst  harm,  rather  than  as  a  means  of  direct  benefit  to  the 
infant  in  disease. 

We  must  also  recognize  the  clinical  fact  that  this  elimination  may  occur 
at  any  time  during  the  nursing  period  in  the  breasts  of  women  who,  so  far 


132  PEDIATRICS. 

as  Ave  can  ascerlaiu.  are  in  a  perfectly  healthy  condition.  Thus,  every 
practitioner  has  at  times  doubtless  observed  the  laxative  effect  on  the  infant 
of  such  drugs  as  compound  liquorice  powder  given  to  the  mother;  and  a 
case  has  lately  come  to  our  notice  where  an  infant  vomited  for  weeks  while 
taking  the  milk  from  ilie  breast  of  its  mother,  who  was  urnisually  well 
and  strong,  but  who  was  in  the  habit  of  drinking  a  considerable  quantity 
of  porter  daily.  After  the  porter  was  omitted  the  vomiting  ceased  at  once, 
and  did  not  return. 

These  facts  warn  us  that  the  use  of  drugs  during  the  period  of  lactation 
should  be  far  more  limited  than  at  other  times,  and  that  the  medicinal 
treatment  of  disease  in  infants  is  exceedingly  inexact.  Saline  cathartics 
may  not  only  act  unfavorably  on  the  infant  through  the  mammary  excre- 
tion, but  may  lessen  very  decidedly  the  flow  of  the  milk,  and  even  stop  it 
altogether. 

Menstruation. — In  deciding  whether  a  return  of  the  menstrual  period 
necessarily  contra-indicates  the  continuation  of  nursing  we  cannot  adopt 
and  follow  an  inflexible  rule,  but  must  be  guided  by  what  seems  best  for 
the  individual  case.  Infants  are  at  times  affected  so  seriously  by  the  alter- 
ation in  the  constituents  of  the  milk  which  occurs  once  in  four  weeks  that 
their  nutrition  is  markedly  interfered  Avith,  and  a  change  to  a  more  stable 
food  is  indicated.  Again,  the  only  disturbance  which  may  arise  is  a  tem- 
porary and  slight  digestive  attack  for  a  day  or  two,  which  apparently  docs 
not  materially  affect  the  infant,  and  makes  us  hesitate  to  run  the  risk  of 
depriving  it  of  a  food  on  which  it  thrives  during  twenty-six  days  out  of 
twenty-eight.  It  is  better  not  to  be  too  hasty  in  concluding  from  the  bad 
symptoms  in  the  infant  that  Ave  should  at  once  AvithdraAv  it  permanently 
from  the  breast,  for  the  catamenia  may  appear  once,  and  then  not  again 
for  a  number  of  months,  the  infant's  poAvers  of  digestion  in  the  mean 
time  becoming  so  much  more  fully  developed  that  they  are  unaffected  by 
the  milk  of  the  catamenial  period.  Even  Avhen  the  catamenia  recur  regu- 
-larly,  the  disturbance  Avhich  may  have  been  great  at  one  period  may  for 
many  reasons  fail  to  recur  at  the  next ;  so  that  the  question  is  reduced  to 
whether  the  composition  of  the  milk  shows  a  recovery  of  the  equilibrium 
of  its  constituents  Avithin  a  fcAV  days,  or  remains  affected  to  such  a  degree 
as  to  endanger  the  integrity  of  the  infant's  nutrition. 

Our  experience  is  in  favor  of  alloAving  the  infant  to  continue  Avith 
the  breast,  unless  it  is  decidedly  contra-indicated  by  circumstances  such 
as  have  just  been  mentioned.  We  have  seldom  met  cases  Avhich  could  not 
Avithout  permanent  injury  be  tided  over  the  small  amount  of  temporary 
digestive  disturbance  Avhich  may  arise.  There  have,  as  yet,  been  too  feAV 
analyses  made  during  the  catamenial  period  to  justify  us  in  drawing  any 
definite  conclusions  as  to  the  chemical  status  of  the  question  ;  but  the 
probability  is  that  the  milk  will  be  found  to  be  deficient  in  fat  and  to  have 
its  proteids  increased,  folloAving  the  general  rule  of  disturbed  mammary 
secretion,  and  that  consequently  it  is  in  a  condition  to  interfere  temporarily 
Avith  botli  digestion  and  nulrilion. 


FEEDING.  133 

Pregnancy. — A  much  more  serious  question  arises  when  the  nursing 
mother  becomes  pregnant ;  for  here  the  almost  universal  clinical  experi- 
ence is  that  the  infant,  for  various  reasons,  cannot  continue  to  be  fed  by 
its  mother,  it  being  unusual  for  a  woman  to  have  sufficient  vitality  to 
nourish  properly  her  living  child  and  growing  foetus.  The  danger  of  reflex 
miscarriage  from  the  continual  irritation  of  the  mammary  gland  by  nursing 
we  personally  have  had  no  experience  with,  but  this  is  mentioned  as  one 
of  the  dangers  contra-indicating  the  continuation  of  nursing  by  a  pregnant 
woman.  We  must,  however,  here  also  not  judge  hastily,  but  take  all  the 
circumstances  of  the  case  into  consideration  before  deciding  on  a  measure 
of  such  vital  importance  to  both  child  and  fcetus.  If  the  mother  remains 
strong  and  vigorous,  and  the  analysis  of  her  milk  shows  no  deterioration, 
while  the  infant  is  a  delicate  one  just  beginning  to  thrive  on  its  rightful 
supply  of  natural  food,  or  if  it  is  during  a  hot  period  of  the  year,  and 
especially  when  a  wet-nurse  or  feeding  from  a  milk-laboratory  cannot 
be  employed,  it  will  often  be  Aviser  to  take  some  risk  and  continue  the 
nursing  for  a  certain  time,  perhaps  six  or  eight  weeks,  and  then,  according 
to  circumstances,  gradually  to  substitute  another  food.  Almost  every 
case  wdll  differ  in  the  questions  to  be  decided,  and  must  be  judged  on  its 
own  indications  and  contra-indications,  always,  however,  recognizing  the 
accepted  rule  that  lactation  and  pregnancy  are  usually  incompatible. 

Acute  Illness.— ^It  is  difficult  to  lay  down  rules  as  to  the  management 
of  breast  feeding  when  the  mother  is  taken  with  an  acute  illness.  In  no 
case  should  her  interest  be  sacrificed  for  the  sake  of  the  child,  for  modern 
methods  of  substitute  feeding,  intelligently  applied,  are  so  well  developed 
that  a  physician  should  not  hesitate  to  wean  an  infant  if  the  mother's 
health  makes  this  desirable.  In  the  acute  fevers,  not  septic,  bacteria  do 
not  appear  in  the  breast-milk,  and  if  the  strength  of  the  mother  permits, 
nursing  may  be  continued.  If  there  is  tuberculosis  in  the  mother,  or  a 
strong  tendency  toAvards  it,  nursing  is  contra-indicated.  In  suppurative 
inflammation  of  the  mammary  gland  in  puerperal  and  other  septic  condi- 
tions, bacteria  may  be  eliminated  in  the  milk,  from  which  it  is  well  to 
protect  the  infant.  In  diphtheria,  whooping  cough,  and  severe  forms  of 
contagious  diseases  it  is  safer  not  to  permit  nursing,  although  it  has  been 
shown  that  a  certain  amount  of  immunity  is  often  conveyed  to  the  infant 
through  the  milk,  in  cases  of  measles,  scarlet  fever,  diphtheria,  mumps, 
and  typhoid  fever,  probably  from  the  elimination  of  immune  bodies.  The 
acute  diseases,  if  severe,  often  cause  the  milk  entirely  to  disappear,  even 
when  the  nursing  is  continued. 

Management  of  Disturbed  Lactation. — The  nursing  mother  is  inclined 
to  believe  that  if  she  feels  w^ell  and  strong  her  milk  must  be  good  for  her 
infant  under  all  circumstances.  She  therefore  frequently  transgresses  the 
rules  which  are  necessary  for  keeping  her  milk  in  equilibrium,  and  she 
should  be  made  to  understand  that  sometimes  abnormal  variations  are 
liable  to  arise,  however  good  her  general  health  may  be.     She  is  simply 


134 


PEDIATRICS. 


fulfilling  a  task  demanded  by  nature  from  those  \vho  l^ear  children,  and  her 
duty,  when  once  she  has  undertaken  to  nurse,  is  to  prevent  as  much  as 
possible  these  variations  by  regulating  her  life  to  a  normal  standard  and 
avoiding  excitement.  Both  of  these  requisites  of  a  normal  lactation  come 
within  the  province  of  the  physician  to  explain  as  he  would  any  other 
branch  of  rational  medicine.  He  should  impress  upon  her  that  emotional 
mothers  do  not  make  good  nurses,  and  that  the  physiological  influence 
of  the  emotions  on  the  nervous  system,  with  its  resulting  changes  in  the 
mammary  secretion,  has  necessarily  a  much  wider  range  in  women  who 
are  subjected  to  the  customs  and  vicissitudes  of  modern  life  than  it  has  in 
those  who  live  in  a  more  natural  way. 

The  following  table  shows  the  percentages  and  combinations  which 
are  likely  to  occur  in  abnormal  milk : 

TABLE  29. 

Showing  typical  ayialyses  of  a  norinai^  a  poo?;  an  over-rich,  and  a  bad  human  breast-milk. 

Normal  Milk. 

(Healthy  life 

as  to  exercise 
and  food.) 

Fat 4 

Sugar 7 

Proteids 1.60 

Mineral  matter 0.15 

Total  solids 12.65 

Water   87.35 

100.00     100.00      100.00      100.00 


Over-rich  Milk. 

Bad  Milk. 

Poor  Milk. 

(Rich  feeding ; 

( Pregnancy. 

(Starvation.) 

lack  of  exer- 
cise.) 

Disease,  etc. ) 

1.10 

5.10 

0.80 

4.00 

7.50 

5.00 

2.50 

3.50 

4.50 

0.09 

0.20 

0.09 

7.69 

16.30 

10.39 

92.31 

83.70 

89.61 

The  terms  poor  and  bad  milk  are  merely  relative,  and  in  common  use 
do  not  have  a  definite  meaning.  We  have  adopted  the  terms  for  the  pur- 
pose of  simplicity  and  to  distinguish  a  milk  which  can  be  restored  easily  to 
a  normal  condition  from  one  in  which  the  difficulty  of  such  restoration  is 
very  great.  By  a  poor  milk  we  mean  one  which  represents  a  condition  of 
lack  of  nourishment  or  starvation  in  the  mother,  but  one  which  can  easily 
be  changed  by  the  proper  feeding  of  the  mother.  In  this  case  the  normal 
mechanism  of  the  mammary  gland  has  not  been  interfered  with.  By  a 
bad  milk  we  mean  one  which  represents  a  profound  disturbance  of  the 
mechanism  of  the  mammary  gland  produced  by  many  causes,  disease, 
pregnancy,  and  especially  extreme  nervous  conditions  m  the  mother,  and 
one  which  cannot  be  easily  changed  to  a  good  milk. 

Whatever  the  cause  may  be,  the  characteristic  changes  produced  by 
disturbance  in  the  mammary  secretion  are  usually  the  production  of  gas- 
tric or  intestinal  indigestion,  and  if  long  continued,  either  of  loss  of  weight 
or  retarded  physical  development.  Sometimes  the  vomiting  and  diarrhoea 
are  accompanied  by  symptoms  such  as  pain,  fever,  convulsions  and  shock  so 
severe  as  to  suggest  poisoning  by  some  substance.  One  sees,  therefore,  all 
grades  of  disturbance  from  the  mildest  forms,  characterized  only  by  slight  dis- 
comfort and  regurgitation,  to  the  alarming  condition  of  intestinal  intoxication. 


FEEDING.  335 

Causes  acting  in  such  a  way  as  to  weaken  the  milk  as  a  whole  and  lessen 
the  quantity  result  only  in  the  restlessness  and  irritability  during  the  day, 
sleeplessness  at  night  and  malnutrition.  In  such  cases  careful  observa- 
tions of  the  weight  development  and  the  digestive  functions  furnish  the 
indications  as  to  the  wisdom  of  continuing  the  breast  feeding.  Bad  breast- 
milk  may  be  as  productive  of  danger  to  the  child  as  an  improper  modifica- 
tion of  an  impure  milk-supply.  In  normal  breast  cases  very  little  super- 
vision of  the  feeding  is  necessary  aside  from  the  regulation  of  the  number, 
intervals,  and  length  of  feedings. .  In  the  management  of  the  pathological 
cases,  however,  the  greatest  difficulty  is  often  experienced.  The  treatment 
is  of  two  kinds,  that  directed  toward  the  mother,  the  source  of  the  trouble, 
and  that  which  applies  to  the  infant. 

One  should  never  lose  sight  of  the  fact  that  the  most  important  under- 
lying principle  of  all  is  the  removal  of  the  cause  affecting  the  mother.  If 
habits  of  life. or  family  worries  are  at  the  bottom  of  the  trouble  no  rules  which 
can  be  given  will  avail.  A  mother  is  often  in  a  very  weakened  condition 
following  labor.  Her  digestion  and  health  must  be  attended  to  according 
to  the  general  principles  of  hygiene  and  therapeutics.  Tears  of  cervix  and 
perineum  should  be  repaired  as  soon  as  practicable.  Fresh  air,  exercise, 
tonics,  aids  to  digestion,  laxatives  and  proper  food  should  be  prescribed. 
Above  all  she  should  be  encouraged  in  her  hopes  that  she  will  in  time  be 
able  to  nurse  her  offspring. 

The  treatment  of  the  infant  in  the  great  majority  of  cases  will  be  wholly 
through  the  mother.  It  will  be  necessary,  however,  in  the  more  difficult 
cases  to  take  the  child  temporarily  from  the  breast  and  to  give  it  a  proper 
modified  milk.  The  mother's  milk  is  then  regularly  withdrawn  by  means 
of  a  breast-pump,  while  her  own  treatment  is  being  carried  out.  This  will 
relieve  her  of  the  anxiety  she  naturally  feels  from  noticing  the  effect  of  her 
milk  upon  her  child. 

When  the  symptoms  of  indigestion  are  mild  the  baby  is  kept  upon  the 
breast-milk,  and  while  the  mother  is  being  treated  the  symptoms  in  the 
infant  are  met  by  appropriate  remedies.  If  the  vomiting,  for  instance,  is 
due  to  a  milk  that  is  abundant  but  too  rich,  the  nursing  period  may  be 
limited  to  the  fore  and  middle  milk,  while  the  strippings  are  withdrawn  by 
a  breast-pump  and  discarded.  Or  if  the  quantity  of  the  milk  is  scanty  and 
the  quality  too  rich,  the  baby  may  be  given  boiled  water,  or  diluted  lime- 
water,  or  a  weak  bicarbonate  of  soda  &olution  before  each  nursing.  If 
there  is  intestinal  indigestion  with  loose  movements,  bismuth  in  three  to 
five  grain  doses  may  be  tried  from  three  to  six  times  a  day.  A  new  prepa- 
ration, known  as  "  milk  of  bismuth,"  makes  a  very  satisfactory  form  in 
which  to  prescribe  the  bismuth  in  suspension.  Constipation  is  best  re- 
lieved by  small  doses  of  milk  of  magnesia.  Colic  that  persists  in  spite  of 
regulation  of  the  bowels  and  dilution  of  the  milk  as  prescribed,  may  in 
some  cases  be  relieved  by  ten  to  twenty  drop  doses  of  essence  of  pepsin, 
or  by  three  to  five  grain  doses  of  saccharated  pepsin  before  each  nursing 


136  PEDTATRTCS. 

The  following  are  some  of  (lie  rules  wliidi  will  be  I'oimd  of  use  in 
attempting  to  improve  the  quality  of  the  breast  milk  : 

General  Principles  for  Guidance  in  manaifuuf  a  Di><tiirhed  Lactation. 

T<i  iiKTcase  the  total  quantity Increase  proportionately   the   liquids  in  the 

mother's  diet,  iind  encourage  her  to  helieve 
that  she  will  be  enabled  to  nurse  her  infant. 

To  decrease  the  totiil  quantity Decrease   proportionately    the  liquids  in  the 

(Rarely  necessary.)  mother's  diet. 

To  increase  the  total  solids Shorten  the  nursing  intervals  ;  decrease  the 

exercise  ;  decrease  the  proportion  of  liquids 
in  the  mother's  diet. 

To  decrease  the  total  solids    Prolong  the  nursing  intervals  ;  increase  the, 

exercise;  increase  the  projtortinn  of  liquids 
in  the  mother's  diet. 

To  increase  the  fat   Increase  the  proportion  of  meat  in  the  diet 

and  of  fats  which  are  in  a  readily  digestible 
and  assimilable  form. 

To  decrease  the  fat Decrease  the  proportion  of  meat  in  the  diet. 

To  increase  the  proteids Decrease  the  exercise. 

(Yery  rarely  indicated.) 

To  decrease  the  proteids Increase  the  exercise  up  to  the  limit  of  fatigue 

for  the  individual. 

In  attempting-  to  formulate  rules  we  must  understand  that  we  are 
dealing  with  a  subject  of  which  very  little  is  known  definitely.  We  can, 
therefore,  at  present  only  state  our  experience  in  a  large  number  of  cases, 
and  give  some  general  idea  of  how  we  can  recognize  whether  we  are  deal- 
ing with  a  bad  or  poor  milk  rather  than  with  a  normal  variation  of  a  good 
milk.  This  knowledge  of  the  variations  which  take  place  in  human  milk 
is  of  the  utmost  clinical  importance  during  the  period  of  lactation,  for  it  is 
the  only  means  by  whicli  we  can  decide  definitely  and  intelligently  many 
vital  c|uestions  in  this  period. 

~'  Instances  have  continually  been  brought  to  our  notice  where  infants 
have  been  allowed  either  to  continue  with  their  mother's  milk  when  they 
were  not  thriving  on  it,  simply  because  it  was  mother's  milk,  or,  on  the 
other  hand,  have  been  Aveaned  from  their  mothers  for  what  would  evi- 
dently have  been  insufficient  reasons  had  the  case  been  thoroughly  under- 
stood. In  both  instances  a  proper  knowledge  of  what  can  be  done  with 
human  milk — that  is,  with  the  management  of  its  different  constituents  by 
increasing  or  decreasing  their  relative  proportions — would  have  been  of 
benefit  to  both  mother  and  child,  and  in  some  cases  would  have  saved  the 
life  of  the  latter.  This  lack  of  knowledge,  or  rather  lack  of  adaptation  of 
the  knowledge  which  we  possess  of  this  branch  of  medicine  is,  to  say  the 
least,  reprehensible,  and  in  other  branches  of  our  art,  which  are  more  intel- 
ligently and  carefully  studied,  would  be  deemed  inexcusable.  Physicians 
are  continually  stating  to  their  patients  that  human  breast-milk  is  the  best 
food  for  infants,  and  at  the  same  time  are  content  to  ignore  the  very 
principles  which  would  make  their  statements  true.     We  should  under- 


FEEDIXG.  137 

stand  that  when  we  speak  of  the  superiority  of  breast-milk  as  a  food,  we 
mean  good  average  breast-milk  and  for  the  average  infant. 

A  sedentary  life,  with  abundance  of  rich,  mixed  food,  provided  the 
w^oman  has  a  strong,  healthy  digestion,  appears  to  increase  the  total  solids 
and  to  decrease  the  water.  This  increase  is  almost  always  in  the  fats 
and  proteids  rather  than  in  the  sugar  and  mineral  matter ;  in  fact,  the 
marked  variations  in  human  milk  are  almost  always  shown  in  the  fat  and 
proteids,  and  hence  our  attention  must  almost  invariably  be  directed  to 
correcting  these  elements.  This  is  fortunate,  as  we  know  of  no  special 
treatment,  except  on  very  general  principles,  by  which  we  can  alter  the  pro- 
portion of  sugar  or  salts  to  the  other  constituents.  A  meat,  or  rather  a 
nitrogenous,  diet  and  fat  in  an  easily  digestilDle  and  assimilable  form  in- 
crease the  fat  in  breast-milk.  The  proteids  are  more  difficult  to  deal  wdth. 
They  have  a  tendency  to  increase  in  very  bad  and  in  very  rich  milk.  The 
problem  which  we  have  to  solve  is  almost  always  how  to  decrease  them, 
no  matter  what  the  milk  is.  Our  knowledge,  unfortunately,  concerning 
a  sure  means  of  reducing  the  proteids  is  very  limited.  Practically,  how- 
ever, we  have  found  that  when  the  woman  is  in  good  health  it  is  physical 
exercise  which  we  must  insist  upon,  preferably  walking  in  the  open  air 
and  within  the  limits  of  fatigue.  A  walk  of  from  one  to  two  miles  twice 
daily  Ave  have  found  to  be  about  what  the  average  healthy  woman  in  New- 
England  needs  to  reduce  the  percentage  of  the  proteids  in  her  milk ;  but 
the  amount  of  exercise  must  be  carefully  regulated  according  to  the 
physical  capabilities  of  the  indiAidual. 

Bearing  in  mind  these  simple  rules,  and  having  determined,  by  means 
of  an  analysis  or  analyses,  the  cause  of  the  special  disturbance,  it  is  often 
possible  to  regulate  the  nursing  period  in  cases  in  Avhich  a  lack  of  this 
knowledge  would  necessitate  weaning.  In  this  way  also  serious  harm  to 
the  infant  may  be  avoided. 

The  following  tables  represent  the  changes  wliich  took  place  in  the 
milk  in  certain  cases  of  disturbed  lactation. 


TABLE   30. 

{^Human  Milk.^ 

Showing  the  influence  of  a  luxurious  life  on  a  porhj fed  hid  hrnWnt  '\rrf-vurae. 

HI.  IV. 

Rich  food  and  but       p^^^  ^^^  exercise 

little  exercise  for  regulated. 
a  month. 

6,44  5.50 

6.25  6.60 

4.61  2.90 

0.20  0.14 

16.50  15.14 

83.50  84.86 


Pat  „ 

I. 

Normal. 

4.00 

T'svo 

clis 

11. 

days    before 
mge  of  food. 

0.72 

Susrar 

7.00 

6.75 

Proteids , . 

1.50 

2.53 

Mineral  matter 

,....       0.15 
12.65 

0.22 

Total  solids 

10.22 

"Water 

87.35 

89.78 

100.00 

100.00 

100.00  100.00 


13« 


PEDIATRICS. 


TABLE  31. 

{^Human  Milk  ) 

Showing  a  bad  milk  atid  one  whicJi  it  wa.'s  impossible  to  manage  on  account  of  the  contimied 
recurrence  of  the  satne  cause,  uncontrolled  emotions. 

Emotions  causing  dis- 
turbance in  infant'; 
digestion. 


Normal. 

Fat 4.00 

Sugar 7  00 

Pioteids 1, 50 

MincT^l  matter , 0. 15 

Total  solids 12.65 

Water 87.35 

100.00 


0.62 
5.80 
4.21 
0.20 
10.83 
89.17 

100.00 


TABLE    32. 

[Human  Milk.) 

Showing  a  milk  possible  to  manage,  because  the  mother,  though  excitable,  was  able  and  willing 

to  control  her  emotio7is. 


Fat 

Sugar , 

Normal. 

.  .        4.00 
7.00 

Infant  doing  badly. 
Colic.        Mother 
before  treatment. 

1  62 
6.10 
3.54 
0.17 

Infant  doing 
Mother 
treatment. 

3.20 
6.40 
2.52 
0.18 

12.30 
87.70 

well, 
after 

Wet-nurse  pro- 
vided but  not 
used 

3.04 
6.60 

Proteids 

Mineral  matter. . . , 

..        1.50 
...       0.15 

2.32 
0.12 

Total  solids 

. .     12.65 

11.43 

88.57 

12.08 

Water 

, ..     87.35 

87.92 

100.00 

100.00 

100.00 

100.00 

In  the  above  case  the  mother  was  very  nervous  and  v\-ished  to  nurse 
her  infant,  but  thought  that  she  could  not,  as  she  had  been  discouraged 
by  her  nurse  and  physician.  She  was  then  told  that  she  could  nurse  in  a 
Tveek,  if  in  the  mean  time  she  took  proper  food  and  exercise  and  ^^'ithdrew 
the  infant  from  the  breast.  This  she  did,  and  had  her  breasts  regularly 
pumped,  A^ith  good  results. 

TABLE    33 

{^JSuynayi  Milk.) 

Showing  the  effect  of  the  catamenia  on  hu/man  inilk. 

Normal  Catamenia,  Seven  Days  after        Forty  Days  after 

Second  Day.  Catamenia.  Catamenia. 

Fat 4.00  1.37  2.02  2.74 

Sugar 7.00  6.10  6.55  6.35 

Proteids 1.50  2.78  2.12  0.98 

Mineral  matter. . .  0.15  0.15  015  0.14 

Total  solids 12.65  10.40  10.84  10.21 

Water 87.35  89.60  89.16  89.79 

100.00  100.00  100.00  100.00 


FEEDING. 


189 


TABLE  34. 

{^Human  Milk.) 

Showing  a  milk  i?i  which  the  proteids,  which  were  disturbing  the  infant,  could  not  he  reduced 
until  the  another  was  inade  to  walk  comfortably,  and  thus  without  fatigue. 


Kormal. 


Pat 4.00 

Sugar. 7.00 

Proteids 1.50 

Mineral  matter...  0.15 

Total  solids 12.65 

Water. 87.35 


100.00 


Infant     with     colic 
and  vomiting. 

Mother  taking 
no  exercise  and 
very  rich  food. 

3.05 
6.10 
8.89 
0.16 

13.20 
86.80 

100.00 


Infant  as  before. 
Mother  walking 
two  miles  daily, 
but  having  blis- 
ters from  uncom- 
fortable shoes. 

0.65 
5.25 
3.82 
0.18 

9.90 
90.10 


Infant  doing  well. 
Mother  walking 
two  miles.  Easy 
shoes,  no  blisters 

3.34 
6.30 
2.61 
0.16 


100.00 


12.41 

87.59 

100.00 


TABLE   35. 

{Human  Milk.) 
Showing  how  a  milk  can  be  managed  while  the  nursinq  is  continued. 


Normal. 


Fat 4.00 

Sugar 7.00 

Proteids 1.50 

Mineral  matter  0.15 

Total  solids .. .   12.65 
Water 87.35 

100.00 


nfant  two  weeks 

old,  -with  serious 
general  nervous 
symptoms     and 
pain.        Mother 
eating        much 
meat  and  taking 

Mother  walking 
and  eating  less 
meat.        Infant 
entirelj'  well. 

Infant  when  four 
months  old,  with 
pain     and    diar- 
rhoea.        Mother 
not    walking    so 
much. 

Infant  doing  well. 
Mother   walking 
two  miles  daily. 
Milk  diluted  one- 
fifth. 

no  exercise. 

3.44 

2.09 

3.98 

3.19 

5.60 

6.70 

7.00 

5.60 

3.96 

1.38 

2.22 

1.78 

0.20 

0.15 

0.19 

0.16 

13.20 

10.32 

13.39 

10.73 

86.80 

89.68 

86.61 

89.27 

100.00 


100.00 


100.00 


100.00 


As  is  seen  from  the  last  analyses,  the  infant  did  not  do  well  until  the 
mother  began  to  exercise,  and  at  four  months  it  was  again  affected  by 
apparently  the  high  percentage  of  the  proteids.  The  infant  was  consid- 
erably under  the  weight  corresponding  to  that  of  the  average  infant  of 
four  months.  It  was  found  to  nurse  twenty-five  minutes  at  a  time,  and  by 
calculation  from  its  weight  before  and  after  nursing,  it  was  found  to  take 
from  80  to  120  cc.  (20  to  30  drachms).  This  amount  being  larger  than 
the  probable  size  of  its  stomach  demanded,  the  time  of  the  nursing  was 
reduced  to  twenty  minutes,  and  20  cc.  (5  drachms)  of  sterilized  water 
were  given  in  the  middle  of  the  nursing,  thus  changing  the  percentages  in 
the  milk  to  the  figures  which  are  represented  in  the  last  column.  This 
calculation  is  on  the  basis  of  100  cc.  (25  drachms)  to  each  nursing. 

So  long  as  this  method  of  feeding  was  adhered  to,  the  infant  did  well. 
It  was  evidently  a  case  in  which  the  infant  could  not  digest  over  two  per 
cent,  of  proteids. 


140 


PEDIATHK'S. 


TABLE  m. 


[Human  Milk.] 


Showing  that  even  for  a  lonp  interval  the  breasts  map  hr  puynped  and  the  residt  he  a 

successful  nursing. 


Normal. 

Pat   4.00 

Sugar 7.00 

Proteids 1.50 

Mineral  matter 0. 15 

Total  solids 12.65 

Water 87.35 

loo.ocT 


Infant  showing  nervous 

Infant  i 

showing  no  uric 

symptoms    and 

much 

acid 

and      thriving. 

uric      acid. 

Mother 

Mother    walking    two 

taking  no  exercise  and 

miles 

and   not  eating 

much  rich  food. 

much 

meat. 

5.71 

2.67 

4.00 

6.60 

4.29 

3.18 

0.19 

0.17 

14.19 

12.62 

85.81 

87.38 

100.00 


100.00 


In  this  case  the  infant  was  withdrawn  from  the  breast  temporarily,  and 
the  breasts  pumped  for  twenty-seven  days.  When  the  analysis  presented 
the  figures  seen  in  the  last  column,  the  milk  was  treated  by  diluting  it,  as 
in  the  previous  case,  and  the  infant  was  put  back  to  the  breast. 

TABLE  37. 

[Ifuman  Mi'lk.) 
Showing  the  valice  of  retaining  the  breast-milk  by  managing  even  an  imj^romlsing  case. 

Infant  with  colic 

and     failing.  Infant    put    on 

Mother  no  ex-  bottle.  Breasts    Exercise    in- 

ercise,  nursing  pumped  every        creased  to  two    Eating    much 

irregularly,  four        hours.        miles.      Small       meat.      Exer- 

NormaL       irregular    and  Moderate    ex-       amount     of       cise  the  same, 

improper  ercise, — one       meat. 

sweet       food.  mile.        Full 

Nervous,  wor-  regular     diet, 

ried  condition.  Tranquil. 

Fat 4.00                    0.34  3.24                    2.79                    4.84 

ugar 7.00                    5.40  5.45                    5.05                    6.00 

Proteids 1.50                    3.61  3.95                    3.66                    3.42 

Mineral  matter...        0.15                     0.18  O.IG                     0.20                     0.17       " 

Total  solids ^2M>  9.53  12.80  11.70  14.43 

Water 87.35  90.47  87.20  88.30  85.57 

100.00  100.00  100.00  100.00  100.00 

The  last  case  represents  a  bad  milk  from  the  failure  of  the  healthy 
mother  to  conform  to  the  rules  of  lactation.  This  bad  milk,  represented 
in  the  second  column,  had  to  be  made  into  a  rich  milk  by  regular  feeding 
before  any  attempt  could  be  made  to  alter  the  ratio  of  the  constituents. 
The  proteids  were  then  reduced  somewhat  by  exercise,  and,  after  the 
breasts  had  been  pumped  for  two  weeks,  the  analysis  showed  the  percent- 
ages as  represented  in  the  last  column.  The  milk  was  then  diluted  with 
sterilized  water,  and  the  infant  was  put  to  the  breast  and  did  well ;  in  fact, 
was  carried  through  an  attack  of  retro-pharyngeal  abscess  with  this  breast- 
milk. 


FEEDING.  141 

The  decrease  in  the  total  quantity  of  the  milk  is  of  ordinary  occurrence 
at  any  time  during  lactation,  but  it  is  most  common  among  civilized  races 
at  about  the  eighth  to  the  tenth  month.  When  it  occurs  early  in  the  lac- 
tation it  is  very  disheartening  to  the  mother  if  she  is  desirous  of  continuing 
her  nursing.  She  becomes  fearful  that  the  flow  of  milk  may  stop  alto- 
gether, and  the  nervous  influence  thus  brought  to  bear  on  the  mammary 
gland  tends  to  increase  the  disturbance.  We  should  therefore  encourage 
her  to  beheve  that  the  milk  Avill  return.  The  following  case  illustrates 
what  has  just  been  said  : 

The  mother  was  much  discouraged  because  her  milk;  lessened  in  quantity  early 
in  the  lactation,  and  she  was  convinced  that  it  would  not  return.  She  had  been 
taking,  without  our  knowledge,  a  disproportionately  small  amount  of  fluid  in  her  diet. 

There  was  an  element  in  this  case  which  the  intelligent  nurse  brought  to  our  notice, 

namely,  that  the  infant  was  not  vigorous,  and  when  put  to  the  breast  sucked  feebly 
and  called  upon  the  gland  for  very  little  milk.  Reacting  to  this  lack  of  stimulus,  the 
gland,  although  in  a  normal  condition,  secreted  only  the  small  amount  demanded  by 
the  infant,  and  the  milk  lessened  diy  by  day.  Treatment  was  instituted  on  the  sup- 
position that  the  mammary  gland  is  practically  self-regulating  as  to  the  amount  of 
food  wliicli  it  will  elaborate  at  a  given  nursing.  If  it  happens  to  be  called  upon  to 
nourish  twins,  it  will  increase  the  amount  of  its  supply.  If  the  infant  wdiich  is  put 
to  it  has  a  small  gastric  capacity,  it  will  produce  the  amount  needed  for  that  capacity. 
We  assured  the  mother  that  the  milk  w^onld  return,  and  we  treated  dii-ectly  the  mammary 
gland  itself.  An  increase  was  made  in  the  amount  of  liquid  in  the  mother's  diet,  and 
the  breasts  were,  after  each  nursing,  pumped  gently,  skilfully,  and  thoroughly.  The 
breast-pump  supplemented  the  feeble  action  of  the  infanl,  and  when  more  work  Avas 
required  of  the  gland  it  began  to  produce  more  milk.  The  increase  in  the  liquid  diet 
supplied  the  gland  with  materials  to  work  with,  and  its  mechanism  ceased  to  be  dis- 
turbed by  the  nervous  influence  emanating  from  the  mother.  She  became  cheerful 
when  she  found  the  milk  returning,  while  the  infant,  now  that  the  milk  could  be 
procured  more  easily,  demanded  more,  sucked  more  vigorously,  and  thus  satisfied  the 
sensitive  mechanism  of  the  mammae. 

The  next  case  points  to  the  possibility  of  our  being  at  times  too  hasty 
in  the  decision  to  deprive  an  infant  of  its  mother's  milk. 

The  mother,  a  rather  delicate  primipara,  twenty-five  years  of  age,  was  delivered 
of  a  boy  seven  pounds  in  weight.  Within  four  hours  puerperal  convulsions  set  in, 
from  which  she  recovered,  but  was  left  with  albuminuria  0.25  per  cent,  and  casts. 
The  latter  disappeared  in  a  few  days,  but  the  albumin,  although  somewhat  dimin- 
ished, continued  ;  and  the  patient,  naturally  of  a  calm  disposition,  was  in  a  highly 
nervous  condition,  fearing  that  she  could  not  nurse  her  infant,  but  decidedly  opposed 
to  having  a  wet-nurse.  The  milk  appeared  in  considerable  quantity  on  the  fifth  day, 
but  the  infant  did  not  thrive,  and,  although  it  gained  somewhat  in  weight,  was  very 
fretful,  slept  very  little,  and  looked  ill,  so  that  the  attending  physician  became 
alarmed,  and  after  treating  it  for  its  dyspepsia  without  much  success  until  it  was  five 
weeks  old,  and  finding  that  there  was  still  about  0.25  per  cent,  of  albumin  in  the 
mother's  urine,  decided  with  us  that  the  breast-milk  should  be  withheld  until  w^e 
could  determine  the  cause  of  the  trouble,  and  an  analysis  was  accordingly  made,  with 
tlie  following  result : 


142  PEDIATRICS. 

Fat 1.62 

Sugar 6. 10 

Proteids 3.54 

Mineral  matter 0. 17 

Total  solids 11.4.3 

Water 88.57 

100.00 

This  analysis  suggesting  the  probability  that  the  large  amount  of  proteids  was 
causing  the  disturbance  of  digestion,  and  that  the  small  amount  of  fat  was  not  suffi- 
cient for  nutrition,  the  attending  physician  was  very  anxious  to  procure  a  wet-nurse  ; 
but  while  we  were  endeavoring  to  get  a  proper  one,  we  decided  to  empty  the  mother's 
breasts  with  the  breast-pump  every  day.  thus  relieving  her  from  the  worry  of  attempt- 
ing to  nurse  her  infant  and  seeing  it  fail  to  gain.  She  also  obtained  in  this  way  un- 
disturbed nights  and  a  great  deal  of  out-door  life.  The  infant  was  in  the  mean  time 
placed  on  a  substitute  food,  which  was  digested  very  well,  and,  as  it  ceased  to  cry, 
the  mother's  mind  became  tranquil,  and  the  albumin  in  her  urine  in  a  few  days  was 
reduced  to  a  trace.  The  treatment  was  carried  out  for  a  week,  the  milk  continuing 
to  flow  freely,  and  an  analysis  (I.)  was  then  made  of  the  mother's  milk  and  also  of 
that  of  a  healthy  wet-nurse  (II.)  whose  infant  was  thriving  on  its  mother's  milk. 

I-  II. 

Mother.  Wet-Nurse. 

Pat 3.20  3.04 

Sugar 6.40  6.60 

Proteids 2.52  2.32 

Mineral  matter 0.18  0.12 

Total  solids 12.30  12.08 

Water    87.70  87.92 

100.00  100.00 

The  two  milks  being  equally  good,  it  was  decided  to  allow  the  infant  to  begin  to 
take  one  nursing  daily  from  its  mother,  although  the  proteids  were  still  about  one  per 
cent,  higher  than  the  infant  seemed  likely  to  digest ;  it  was  given  to  its  mother,  nursed 
well,  seemed  satisfied,  digested  its  meal  without  trouble,  and  at  six  months  was  still 
being  nursed  and  was  thriving. 

The  next  case  illustrates  the  principle  that  too  frequent  nursing  lessens 
the  water  and  increases  the  total  solids  in  human  milk,  making  it  re- 
semble in  a  certain  way  condensed  milk.  It  also  illustrates  what  has 
been  stated  concerning  the  two  important  questions  to  be  considered  in 
the  management  of  a  normal  lactation, — namely,  that  the  digestion  as  well 
as  the  nutrition  must  be  regarded.  This  case  is  one  of  the  numerous  in- 
stances of  the  same  kind  which  have  come  to  our  notice,  and  also  empha- 
sizes the  fact  that  infants  are  often  weaned  from  the  breast  when  tliere  is 
not  the  slightest  necessity  for  it. 

The  mother,  a  healthy  primipara  about  twenty-two  years  old,  had  nursed  her 
infant  for  six  weeks,  during  which  time  the  infant  was  fretful,  suffered  much  from 
colic,  and  never  seemed  satisfied.  There  was,  however,  a  continual  gain  in  weight, 
although  the  fsecal  discharges  showed  evidence  of  the  food  not  being  properly  digested 


FEEDING.  143 

and  were  numerous  and  watery.  By  advice  of  the  attending  ptiysician,  ttie  infant 
was  weaned.  The  mother  came  for  advice  in  regard  to  placing  her  infant  on  a  substi- 
tute food.  On  inquiry  it  was  found  that  this  infant  had  been  nursed  ahnost  continu- 
ously night  and  day,  with  intervals  usually  of  only  one  hour,  and  it  was  evident  that 
the  frequent  nursings  had  resulted  in  producing  a  concentrated  milk  which  the  infant's 
gastro-enteric  tract  was  rebelling  against  and  was  not  digesting,  although  sufficient 
food  was  being  absorbed  to  prevent  up  to  this  time  any  interference  with  the  general 
nutrition.  This  infant,  then  six  weeks  of  age,  was  deprived  of  its  supply  of  good 
human  milk  in  the  middle  of  the  summer  simply  because  the  important  matter  of 
changing  the  intervals  had  not  been  thought  of  as  a  means  of  improving  the  milk 
and  relieving  the  pain  and  apparent  hunger.  There  seems  to  be  no  doubt  that  if  the 
milk  in  this  case  had  been  properly  managed  it  would  have  agreed  perfectly  with  the 
infant.  We  would  also  add  in  connection  with  this  case  that  when  the  digestion  is  not 
carried  on  properly  the  nutrition  must  soon  suffer,  and  it  is  only  in  the  early  weeks  of 
a  disturbed  digestion  that,  as  a  rule,  we  find  the  nutrition  to  be  unimpaired. 

The  next  case  is  one  of  a  multipara  who  was  under  our  care  at  the  City  Hospital, 
and  who  up  to  the  time  of  her  entrance  had  been  nursing  her  infant,  which  was 
thriving.  The  patient  stated  that  her  milk  had  always  been  abundant  and  of  good 
color  up  to  the  time  when  she  was  separated  from  her  infant,  which  was  twelve  hours 
previously,  as  she  had  to  be  away  from  home  for  that  time.  At  the  end  of  twelve 
hours  the  breast  was  found  to  be  so  distended  that  the  breast-pump  had  to  be  applied. 
The  milk  was  drawn  with  great  ease,  almost  flowing  of  itself,  and  in  considerable 
quantity,  but  it  no  longer  resembled  the  milk  of  the  previous  nursings  which  had  been 
at  the  proper  intervals.  On  the  contrary,  it  was  clear,  with  very  little  color,  the  total 
solids  were  reduced  to  a  minimum,  and  it  no  longer  would  have  nourished  the  infant. 

The  treatment  of  this  case  was  of  course  to  pump  the  breasts  every  three  hours 
until  the  infant  could  again  be  nursed. 

As  an  illustration  of  the  harm  which  may  come  to  an  infant  from  the 
percentage  of  fat  in  its  mother's  milk  being  too  high,  and  also  of  the 
means  to  employ  either  to  increase  or  to  decrease  the  fat  in  breast-milk, 
this  case  will  be  of  interest. 

The  mother  was  a  healthy  primipara.  She  had  plenty  of  milk,  but  the  infant 
suffered  from  colic  and  had  very  frequent  watery  dejections.  She  was  eating  a  great 
deal  of  meat  three  times  daily  and  not  taking  much  exercise,  so  it  was  naturally  sup- 
posed from  the  symptoms  of  the  infant  and  the  diet  of  the  mother  that  an  ov^er- 
percentage  of  fat  was  one  of  the  elements  which  Avere  disturbing  the  lactation,  and 
that  a  high  percentage  of  proteids  would  also  be  found.  The  analysis  proved  this 
supposition  to  be  correct  : 

Frimipara.    Healthy;   eating  much  meat;  not  taking  much  exercise. 

Fat 4.96 

Sugar (3.60 

Proteids 3.29 

Mineral  matter 0.17 

It  was  therefore  decided  to  reduce  the  meat  to  a  minimum,  which  was  done,  and 
three  days  later  an  analysis  gave  the  following  figures  : 

Eating  little  meat. 

Fat '. 1.73 

Sugar 5.70 

Proteids '. 3.74 

Mineral  matter '  0.13 


144  PEDIATRICS. 

The  milk  was  found  to  be  lessening  in  quantity.  Tlie  infant's  dejections  were  less 
numerous  and  had  more  consistency  ;  l)ut  it  was  not  gaining,  and  continued  to  have  pain. 
In  fact,  the  analysis  showed  a  poor  milk,  or  even  a  bad  one,  as  represented  by  the  usual 
combination  of  a  low  percentage  of  fat  and  a  high  percentage  of  proteids.  The  woman 
was  consequently  made  to  eat  a  moderate  amount  of  meat,  and  to  exercise  more,  and 
three  or  four  days  later  the  analysis  showed  an  improvement  in  the  fat : 

J'Jathu/  iiuidrrafe  amninit  of  went  j  inkhni  morr  e.rrrci.'ie, 

Tat ! '. 2.42 

tSugar    5. 50 

Proteids 8. 55 

Mineral  malter 0.15 

Tne  infant  no\v  began  to  gain  in  weight,  but  continued  to  have  colic,  as  was  expected 
from  the  high  percentage  of  proteids.  The  exercise  was  still  further  increased,  and.  a 
later  analysis  showed  a  decided  lessening  of  the  proteids. 

Exercise  still  j'u/'iJicr  i iicreascd. 

Pat 2.35 

Sugar 6.25 

Proteids 2.69 

Mineral  matter 0.15 

The  infant  then  began  to  have  regular  movements,  of  good  consistency,  and  no 
longer  had  pain  ;  it  also  gained  regularly  in  weight,  and  looked  well  and  strong.  The 
mother  regulated  her  diet,  exercise,  and  sleep  in  accordance  with  the  requirements  of 
her  infant,  and  her  milk  again  became  abundant. 

AVe  shall,  of  course,  often  fail  in  our  attempts  to  manage  the  percent- 
age of  fat  in  this  way,  but  this  case  illustrates  exactly  the  changes  which 
it  is  usually  necessary  to  produce  in  order  to  alter  a  high  fat  percentage. 
The  proteids  also  being  high,  there  was  an  over-rich  milk  to  deal  with  ; 
taking  away  the  fat-producing  element  reduced  the  fat  to  a  low  percentage  ; 
exercise  reduced  the  high  percentage  of  proteids,  and  a  combination  of 
sufficient  meat  and  exercise  finally  produced  a  milk  which  could  be  di- 
gested. 

This  next  case  illustrates  a  number  of  points  in  the  manag-ement  of 
lactation.  A  high  percentage  of  the  proteids  was  creating  the  disturbance 
in  the  infant,  and  it  was  their  final  reduction  through  treatment  that  per- 
mitted the  lactation  to  go  on. 

The  mother,  a  remarkably  healthy  and  vigorous  multipara,  living  in  the  country, 
had  a  plentiful  supply  of  milk.  Her  diet  consisted  mostly  of  vegetables,  and  she  did  not 
take  much  exercise.  The  infant  was  not  thi'iving,  having  had  continued  attacks  of  colic, 
with  frequent  vomiting,  and  it  did  not  gain  in  weight.  The  analysis  showed  a  bad  milk, 
which  was  contrary  to  what  we  should  usually  expect  to  find  in  the  milk  of  a  mother 
who  was  in  such  perfect  health  as  this  one  was. 

Pat 0..52 

Sugar 6.80 

Proteids 2.48 

Mineral  matter 0. 15 

Total  solids 9.95 

Water 90.05 

100.00 


FEEDING.  145 

The  mother  was  instructed  to  eat  meat  and  walk  two  miles  every  day.  One  month 
later,  as  the  infant  had  not  improved,  another  analysis  was  made,  which  showed  that 
the  milk  was  in  a  worse  rather  than  a  better  condition. 

Fat 0.45 

Sugar 6. 15 

Proteids 2.47 

Mineral  matter .  .  0.16 

Total  solids 9.23 

Water 90.77 

100.00 

It  was  found  that  the  mother  had  eaten  meat  but  once  a  day,  and  in  small  quantity; 
also  that  she  had  not  walked  much.  We  then  insisted  on  her  eating  meat  three  times  a 
day,  and  walking  three  miles.  This  she  did  for  two  weeks,  Avhen  the  infant  was  found 
to  have  gained  slightly  in  weight,  but  to  still  have  colic  and  vomiting.  Another  analy- 
sis showed  an  increase  in  the  fat. 

Fat 1.53 

Sugar 6.68 

Proteids 2.4S 

Mineral  matter 0.16 

Total  solids 10.85 

Water 89.15 

100.00 

During  the  next  two  months  the  walking  was  continued,  and  the  meat  increased  in 
quantity.  The  infant  continued  to  vomit  and  to  have  colic  until  the  mother  was  made 
to  ride  on  horseback  every  day,  when  the  pain  ceased,  and  from  that  time  the  infant 
gained  steadily  in  weight,  and  was  well  and  strong  during  the  rest  of  the  lactation.  An 
analysis  made  two  and  one-half  months  after  this  procedure  showed  that  at  last  the  pro- 
teids had  been  reduced  to  come  within  the  limits  of  the  infant's  digestion,  and  that  the 
fat,  although  still  having  a  low  percentage,  had  been  increased  sufficiently  for  the  infant's 
nutrition.  Thus  a  bad  milk  was  finally  changed  to  a  good  one.  This  infant  evidently 
could  not  digest  a  percentage  of  proteids  approaching  2,  but  fortunately  could  l^e  nour- 
ished on  a  low  percentage  of  fat. 

Fat. 2.01 

Sugar 6.90 

Proteids ." 1.54 

Mineral  matter "...  0. 17 

Total  solids 10.62 

Water 89.38 

100.00 
The  next  case  was  that  of  a  poor  milk. 

The  infant  was  four  months  old.  It  was  perfectly  well  and  was  digesting  well,  but 
had  not  gained  for  three  weeks.  The  mother  was  producing  from  her  breasts  a  suffi- 
cient quantity  of  milk,  but  the  analysis  showed  that  this  milk  had  to  be  modified  Avithin 
the  breast  by  a  regulation  of  the  diet  of  the  mother: 

Fat 1.29 

Sugar 6.05 

Proteids 2.93 

Mineral  matter 0.12 

Total  solids 10.39 

Water 89.61 

100.00 
10 


146  PEDIATHICS. 

She  was  consequently  made  to  eat  an  increased  amount  ol'  me;il.  and  in  tin'  inursi' 
of  a  few  weeks  \\\e  infant  was  thriving  and  gaining  in  weight. 

The  next  case  was  that  of  a  wet-nurse  whose  infant  was  digesting  well, 
gaining  in  weight,  and  happened  to  be  of  about  the  same  age  as  that  of 
the  infant  whom  she  was  hired  to  nurse.  In  order  to  see  if  this  nurse's 
milk  would  agree  with  the  foster-infant,  the  nurse  and  her  infant  were 
brought  to  the  house  of  the  foster-child,  and  were  comfortably  lodged  and 
plentifully  fed. 

Twentj'-four  huur<  Inter  both  iulauts  began  to  have  colic  and  green  llecal  discharges. 
An  analysis  of  the  milk  showed  a  high  percentage  of  proteids : 

Fat 3.19 

Sugar 6.40 

Proteids 3.11 

Mineral  matter 0.15 

Total  solids 12.85 

Water 87.15 

100.00 

The  nurse  was  then  given  a  lighter  diet  with  a  greater  proportion  of  liquids,  and  was 
made  to  walk  a  mile  twice  daily.  By  Aveighing  the  infants  just  before  and  just  after 
a  nursing,  it  was  found  that  they  took  from  90  to  120  c.c.  (3  to  4  ounces)  in  fifteen  min- 
utes. The  infants  were  then  allowed  to  nur.se  for  ten  minutes.  30  c.c.  (1  ounce)  of 
sterilized  water  was  next  given  to  them,  and  they  were  then  allowed  to  nurse  for  ten 
minutes  longer.  In  this  way  it  was  estimated  that  they  were  receiving  in  their  stomachs 
120  c.c.  (4  ounces)  of  food  in  which  the  percentage  of  the  proteids  was  under  2.5.  The 
infants  ceased  to  have  colic,  and  the  fyecal  discharges  became  normal.  The  nurse's 
infant  was  then  sent  away.  Two  weeks  later  the  foster-infant  was  thriving,  and,  as 
another  analysis  of  the  milk  showed  a  sufficient  reduction  of  proteids,  the  sterilized 
water  was  omitted  : 

Fat 2.87 

Sugar 6.25 

Proteids 2.90 

Mineral  matter 0.15 

To!al  solids 12.17 

Water 87.83 

100.00 
During  the  rest  of  lactation  the  infant  digested  well  and  gained  fairly  in  weight. 

The  following  case  was  that  of  a  perfectly  healthy  primipara,  wliose 
infant  digested  her  milk  well  and  gained  in  weight. 

The  case  shov.s  how  at  limes  an  infant  can  thrive  on  what  appears  to  be  too  high 
percentage  of  some  of  the  solids  in  the  milk.      The  analysis  of  her  milk  was  as  follows  : 

Fat 4.11 

Sugar 5.90 

Proteids 3.71 

Mineral  matter 0.21 

Total  solids 13.93 

Water 86.07 

100.00 


FEEDING.  147 

III  contrast  to  this  case  was  the  following  one  in  which  the  infant  was 
evidently  thriving. 

The  mother  was  delicate  and  frail,  and  the  infant  was  fed  by  a  healthy-hjoking 
wet-nurse.  In  the  early  part  of  the  lactation  the  infant  did  not  thrive,  and,  as  the 
niother  was  so  delicate,  it  was  not  deemed  advisable  to  attempt  to  improve  the  quality 
of  her  milk.  The  interesting  point  in  connection  with  this  case  is  the  inability  of  the 
infant  to  digest  a  poor  milk  and  its  ability  to  digest  perfectly  well  the  wet-nurse's  milk, 
wliich  in  its  analysis  showed  a  very  high  percentage  of  fats  and  of  proteids  and  a  low 
percentage  of  sugar  :  . 

Fat 4.72 

Sugar 4.55 

Proteids 4.74 

Mineral  mattar 0.19 

Total  solids 14.20 

AVater 85.80 

100.00 

In  the  following  case  it  was  found  impossible  to  change  the  percentages 
of  the  elements  in  the  milk. 

The  woman  had  a  moderate  quantity  of  milk,  and  nursed  her  infant  for  two  or 
three  months.  The  infant  did  not  gain,  it  had  colic,  and  at  times  vomited.  The 
analysis  showed  that  it  was  in  the  class  which  we  have  designated  as  "  bad  :" 

Fat 1.61 

Sugar 4.67 

Proteids 4.07 

Mineral  matter 0.17 

Total  solids 10.52 

Water 89.48 

100.00 

An  increase  of  meal  in  this  mother's  diet  and  more  exercise  had  no  effect  on  the 
percentages  of  the  elements  of  her  milk,  and  the  infant  was  therefore  weaned.  Soon 
after  beginning  to  take  a  substitute  food  from  the  milk-laboratory  the  infant  ceased  to 
have  colic  and  gained  in  weight.  The  percentages  of  the  elements  in  the  substitute  food 
which  produced  such  an  immediate  change  in  the  infant's  condition  were  as  represented 
in  this  prescription  : 

Fat 3.50 

Sugar 7.00 

Proteids 1.00 

It  was  merely  necessary  to  raise  the  percentages  of  the  fat  and  sugar,  and  reduce 
that  of  the  proteids,  in  order  to  produce  this  rapid  and  satisfactory  result. 

The  next  analysis  is  that  of  a  woman's  milk,  which  is  instructive  for  a 
number  of  reasons : 

Fat 2.30 

Sugar 6.65 

Proteids 2.57 

Mineral  matter 0.12 

Total  solids 11.64 

Water 88.36 

100.00 


1-18  PEDIATIUCS. 

The  j^erceutage  of  fat  is  low,  and  that  of  tiie  proteids  i?;  rather  liigli.  Thii  infant, 
with  the  exception  of  being  somewhat  constipated,  was  always  well,  gained  in  weight, 
and  showed  no  digestive  disturbance  during  the  lactation.  This  was  remai-kable,  as 
the  mother's  catamenia  returned  regularly  during  the  lactation  from  the  time  that  the 
infant  was  four  months  old.  There  was  considerable  flowing  at  the  time  of  the  cata- 
menia, and  the  mother  was  habitually  constipated  and  did  not  have  a  very  good  appe- 
tite. The  infant  did  not  seem  to  be  affected  by  any  of  these  conditions.  The  analysis 
of  this  milk  was  made  from  a  specimen  of  the  "middle  milk."'  which  was  taken 
between  the  catamenial  periods. 

It  may  be  of  interest,  in  connection  with  what  has  been  said  concerning  the 
variations  in  the  milk  which  may  arise  from  emotional  causes  and  menstruation,  to 
report  the  analysis  of  a  milk  of  a  mother  and  a  wet-nurse  where  these  influences 
appeared  to  produce  certain  chemical  changes.  The  mother,  a  healthy  but  rather 
delicate  primipara,  the  period  of  whose  jjregnancy  had  been  supervised  by  us  with  the 
greatest  care,  but  whose  temperament  was  subject  to  extremes  of  despondency  and 
excitement,  was  delivered,  after  a  short  and  easy  labor,  of  a  healthy  boy.  She  was 
exceedingly  anxious  to  nurse  her  infant,  hat  within  a  few  hours  after  its  birth  she 
was  seized  with  an  uncontrollable  fear  that  she  would  be  unable  to  do  so.  In  spite  of 
all  the  assurances  to  the  contrary  which  could  be  given  to  her,  and  the  plentiful 
supply  of  milk  which  in  due  time  came  in  the  breasts,  she  remained  in  a  very 
nervous,  despondent  condition.  As  the  infant  began  to  show  decided  signs  of  indi- 
gestion, we  thought  it  best,  before  proceeding  further,  to  investigate  the  composition  of 
the  milk.  The  analysis  resulted  as  follows,  and  plainly  showed  the  necessity  of  not 
persisting  further,  as  it  was  evidently  much  altered  from  unavoidable  nervous  con- 
ditions, which  seemed  likely  to  recur  through  the  whole  of  her  lactation  : 

{Mother  s  Milk.) 

Fat .-..,.- 0.62 

Sugar 5.80 

Proteid.? , . .  .  . 4.21 

Mineral  matter ,..,,..      0.20 

Total  solids 10.83 

Water - . .     89.17 

100.00 

Under  these  circumstances,  a  healthy  wet-nurse,  whose  own  infant  was  strong 
and  thriving,  was  employed,  and  the  foster-infant  immediately  began  to  gain  in 
weight  and  ceased  to  show  any  digestive  disturbance.  Atler  a  month,  however,  it 
was  found  not  tc  have  made  its  weekly  gain,  to  be  unusually  restless,  and  to  be  having 
frequent  ftecal  discharges.  It  ^vas  then  discovered  that  the  wet-nurse  was  menstru- 
ating, and  on  the  second  day  the  following  analysis  of  her  milk  was  made  : 

(  Wet-Xurse. ) 

Fat 1.37 

Sugar    6.10 

Proteids    2.78 

Mineral  matter 0. 15 

Total  solids 10.40 

Water 89.60 

100.00 

The  catamenia  lasted  about  four  days,  and  did  not  return  for  some  months.  The 
infant  after  the  first  twenty-four  hours  showed  no  disturbance  whatever,  soon  began 
to  gain,  and  was  not  affected  by  the  subsequent  occurrence  o£  the  catamenia.     An 


FEEDING.  ]  49 

cUialvf^is,    iTindc  one  week  after  the  i-ataineiiia  liad  ceased,    sliowrd   a.  decided  change 

for  the  hetter  ;  that  is,   increased   fat  and   decreased   proteids.      Forty   days   after   the 

catanienia  a  still  greater  improvement  was  found  in  the  milk,  as  was  anticipated  from 

the  thriving  condition  of  the  infant.     The  change  in  the  percentage  is  shown  in  the 

following  analysis  : 

Seven  Days  Forty  Days 

after  Cat-  after  Cat- 

amenia.  amenia. 

Fat 2.02  2.74 

Sugar 6.55  6.35 

Proteids 2.  ]  2  0.98 

Mineral  matter 0. 15  0. 14 

Total  solids : 10.84  10.21 

Water 89.16  89.79 

100.00  100.00 

The  following  case  is  of  considerable  interest  with  reference  to  what 
has  been  said  in  regard  to  the  incompatibility  of  pregnancy  and  lactation. 
Unfortunately,  a  full  consideration  of  the  condition  of  the  milk  cannot  be 
presented,  as  it  rapidly  disappeared  from  the  breast  after  the  first  analysis 
was  made,  and,  before  another  specimen  could  be  procured,  had  disap- 
peared entirely. 

The  milk  was  taken  from  one  of  our  patients  who  had  been  pregnant  for  three 
months  and  at  the  same  time  was  nursing  an  infant  nine  months  old: 

Fat 7.64 

Solids,  not  fat 6.04 

Total  solids 13.68 

The  infant  at  the  breast  was  not  thriving.  It  had  been  digesting  its  mother's 
milk  perfectly  and  had  been  gaining  in  weight  until  the  pregnancy  had  existed  for  some 
weeks.  At  the  time-the  analysis  was  made  the  infant's  digestion  had  evidently  been 
weakened,  and  as  a  result  it  had  ceased  to  thrive  and  was  rapidly  losing  in  weight. 

This  analysis  will  be  found  to  illustrate  several  facts.  In  the  first  place,  it  repre- 
sents a  very  rich  food.  The  total  solids  are  even  greater  than  appear  in  most  cow's 
milk,  and  the  fat  is  almost  double  the  percentage  which  is  considered  normal  in  both 
human  and  cow's  milk. 

It  also  shows  that  a  food  may  be  unusually  high  in  the  percentage  of  its  total  solids 
and  yet  not  of  a  character  suited  for  the  nutrition  of  an  infant.  The  explanation  of 
this  fact  is  that  although  for  a  time  an  infant  may  digest  fairly  well  a  rich  food,  yet 
that  nature  has  provided  that  the  percentages  of  the  elements  in  its  food  should  remain 
within  certain  limits.  If  these  limits  are  transgressed,  either  by  giving  too  low  or  too 
high  a  percentage  of  any  of  the  solids  in  the  food,  the  nutrition  will  be  interfered  with. 
In  the  latter  case  the  digestive  function  of  the  infant  actually  becomes  weakened,  and 
the  strong  food  soon  begins  to  act  as  a  foreign  body.  The  absorption  of  the  food  is  next 
interfered  with,  and  the  infant  starves  as  readily  on  the  strong  food  which  cannot  be 
absorbed  as  on  the  weak  food  in  which  the  needed  elements  are  lacking. 

This  analysis  also  represents  a  condition  which,  in  the  majority  of  cases  of  preg- 
nancy, occurs  a,fter  the  first  six  or  eight  weeks, — namely,  a  much  disturbed  mammary 
equilibrium.  The  percentage  of  fat  in  proportion  to  that  of  the  solids  not  fat  is  so 
entirely  different  from  the  percentages  of  the  different  elements  in  a  normal  milk  that 
we  may  say  that  this  milk  of  pregnancy  represents  a  condition  of  profound  disturbance. 

This  especial  analysis  must  not  be  taken  as  a  standard  one  for  the  milk  of  preg- 
nant women,  for,  in  all  probability,  analyses  of  milk  under  these  conditions  differ  very 
widely,  yet  invariably  show  an  absence  of  the  normal  percentages. 


loO  I'EDIATRK'S. 

Prolonged  Lactatiox. — Jn  heaJthy  women  the  milk  lowards  the  end 
of  a  normal  lactation  has  a  tendency  to  return  to  the  condition  which  we 
notice  at  the  very  beginning  of  lactation  ;  that  is,  the  product  of  the  mam- 
mary gland  becomes  unstable  and  the  percentages  show  a  poor  or  a  bad 
milk.  In  rare  cases  we  have  met  with  women  whose  milk  remained  of  fair 
cjfuality  and  who  could  continue  their  nursing  into  the  second  year  with- 
out apparent  detriment  to  themselves  or  to  their  infants.  There  is,  how- 
ever, no  reason  for  thus  continuing  the  lactation,  even  if  the  mother  is 
healthy  and  the  milk  good,  for  at  the  end  of  the  first  year,  human  milk, 
whether  good  or  bad,  is  not  a  food  which  is  adapted  to  the  corresponding 
stage  of  development  of  the  infant's  digestive  organs.  Unmodified  cow's 
milk  and  cereals  in  some  form  are  much  better  adapted  to  the  stage  of  de- 
velopment of  the  digestive  organs  of  the  second  year,  and  should  therefore 
at  that  time  be  substituted  for  human  milk. 

Mixed  Feeding. — It  not  infrequently  happens  to  nursing  women,  when 
their  general  health  is  not  in  a  normal  condition,  that  the  supply  of  milk, 
while  good  in  quality,  is  not  sufficient  in  quantity  to  satisfy  the  infant,  and 
the  question  arises  whether  the  mother's  milk  should  be  entirely  given  up, 
or  whether  it  should  be  supplemented  by  other  food.  Our  experience  is 
in  favor  of  assisting  the  mother  to  niirse  her  infant  during  the  earlier 
months  of  its  life.  When  the  substitute  food  can  be  carefully  regulated, 
and  when  the  mother's  milk  is  of  good  quality,  this  method  is  superior  to 
that  of  withdrawing  the  mother's  milk  and  feeding  the  infant  exclusively 
upon  a  substitute  food. 

We  have,  on  the  one  hand,  a  better  opportunity  for  regulating  the 
mother's  milk,  by  increasing  or  diminishing  the  number  of  the  substitute 
feedings,  and,  on  the  other  hand,  if  the  mother's  milk  agrees  with  her 
infant,  an  jexcellent  opportunity  for  making  our  substitute  food  correspond 
to  what  nature  has  provided. 

In  arranging  a  mixed  feeding  we  should  in  every  case  first  have  an 
analysis  made  of  the  mother's  milk,  and,  if  her  milk  has  been  agreeing 
with  the  infant,  make  the  substitute  food  correspond  to  the  maternal.  It 
is  also  well  to  have  an  analysis  of  the  mother's  milk  made  at  an  early 
period  of  her  lactation,  as  soon  as  the  mammary  gland  has  acquired  its 
equilibrium  and  when  the  infant  is  thriving.  This  is  a  very  important 
precaution,  which  may  be  of  great  use  to  us  at  a  later  period  when  the 
mother's  milk  may  from  many  circumstances  be  disturbed  or  entirely  lost. 
When  such  an  accident  happens,  we  know  exactly  what  the  composition 
of  the  milk  was  on  Avhich  the  infant  was  thriving,  and  can  at  once  arrange 
a  proper  substitute  food. 

The  following  cases  illustrate  this  statement : 

An  infant  was  thriving  on  the  milk  of  a  healthy  wet-nurse.  One  day,  without 
giving  any  warning,  the  nurse  left  the  house  and  never  returned.  The  infant  had  to 
be  put  on  a  substitute  food,  as  another  nurse  could  not  be  procured.  It  was  left  in  the 
middle  of  the  hot  weather  without  the  food  which  had  been  so  well  adapted  to  its 


FEEDIXq.  151 

digestion.  Unfortunately,  tlie  precaution  of  having  an  analysis  made  of  the  wet- 
nurse's  milk  had  not  been  taken,  and  it  was  some  time  before  we  were  able  to  substi- 
tute a  food  which  would  agree  with  the  infant. 

The  second  case  was  where  the  mother's  milk,  after  careful  management,  had  be- 
come fitted  for  her  infant,  and  where  the  infant  was  thriving.  One  day  the  mother 
received  a  nervous  shock  from  seeing  the  arm  of  another  of  her  children  dislocated. 
Within  a  few  hours  the  milk  entirely  disappeared  from  her  breasts  and  did  not  return. 
The  analysis  of  her  milk,  which  had  been  previously  made,  provided  us  with  a  guide 
by  which  we  could  at  once  have  a  substitute  food  prepared  which  would  correspond  to 
the  food  which  the  infant  had  been  receiving  from  its  mother.  This  was  done,  and  the 
infant  continued  to. thrive,  showing  no  bad  symptoms  from  the  change  of  food. 

There  are  certain  points  to  be  considered  in  mixed  feeding.  First,  if 
the  mother's  milk  is  agreeing  with  the  infant,  the  substitute  food  should 
be  of  the  same  composition.  Second,  if  the  mother's  milk  is  fully  digested 
by  the  infant  but  is  lacking  in  certain  nutritive  qualities,  the  absence  of 
which  prevents  the  infant's  nutrition  from  being  normal,  we  should,  after 
the  first  week,  alter  the  composition  of  the  substitute  food  so  as  to  make 
it  fulfil  the  requirements  of  nutrition  by  increasing  the  percentage  of  that 
special  element  hi  the  substitute  which  is  deficient  in  the  composition  of 
the  maternal  milk. 

The  times  at  which  the  substitute  food  should  be  given  wall  depend 
upon  the  number  of  feedings  which  are  found  to  be  necessary  in  addition 
to  the  maternal  feedings,  and  we  should  carry  out  the  same  principles 
in  this  mixed  feeding  that  have  been  laid  down  for  the  general  manage- 
ment of  human  breast-milk.  If  the  mother's  milk  is  lacking  in  quantity 
we  should  make  the  intervals  between  her  nursings  longer,  and  introduce 
one  or  two  substitute  feedings  according  as  the  ag'e  of  the  child  requires 
shorter  or  longer  intervals.  If,  on  the  contrary,  the  mother's  milk  is 
abundant,  but  either  too  strong  or  too  w^eak,  we  should  make  the  intervals 
of  her  nursing  correspondingly  long  or  short.  In  this  way,  with  an  accu- 
rate knowledge  of  the  percentages  which  exist  in  the  mother's  milk,  and 
wath  our  power  to  change  these  percentages  in  substitute  feeding,  we  can 
usually  in  a  week  or  ten  days  regulate  the  substitute  feeding  of  the  infant 
to  such  a  degree  that  the  mother's  milk  will  also  agree  with  the  infant,  and 
the  infant  will  thrive  again. 

WEANING. — There  .is  no  doubt  that  in  a  considerable  number  of 
cases  occurring  in  the  practice  of  physicians  among  civilized  nations  the 
mother's  milk  appears  to  be  entirely  unfit  for  her  olfspring,  and  it  be- 
comes a  question  Avhether  the  infant  shall  be  withdrawn  from  its  mother's 
breast  temporarily  or  entfrely.  In  such  an  emergency  the  careful  and 
repeated  analysis  of  the  milk  will  enable  us  to  determine  this  question 
wisely. 

We  are  convinced  that  a  large  number  of  infants  are  deprived  of  their 
natural  food  and  weaned  on  insufficient  grounds.  We  thus  assist  to  keep 
up  the  resulting  high  mortality  figures,  and  we  believe  that  these  figures  will 
be  sensibly  reduced  when,  in  consequence  of  our  taking  a  more  enlightened 


152  PEDIATliK  S. 

view  of  the  SLibjecl,  wc  iiicrcusc  lln'  iiuiiibi'i' oT  iiifaiils  who  arc  Ibd  (lining' 
the  first  three  or  four  months  of  life  upon  a  suitaJDlo  breast-uiilk. 

A  particular  reason  among  many  for  waiting  at  least  three  or  four 
months  before  weaning  is  presented  by  the  fact  that  the  stomach,  after 
growing  rapidly,  has  by  the  fourth  or  fifth  month  become  a  more  perfect 
receptacle  both  as  to  size  and  to  function. 

A  number  of  nursing  women  find  that  at  variable  periods  in  the  course 
of  their  lactation  their  milk  begins  to  fail,  and  they  are  forced  first  to  lessen 
the  number  of  their  nursings  and  then  to  wean  entirely.  The  time,  then, 
when  the  infant  should  be  weaned  almost  always  settles  itself,  without  our 
intervention,  at  varying  periods.  The  period  of  lactation,  and  the  one 
which  might  be  called  physiologically  normal,  can,  when  the  breast-milk 
remains  of  good  cfuality  and  quantity,  be  carried  through  the  first  year 
with  benefit.  We  have  certain  guides  which  aid  us  in  determining  the 
proper  time  for  beginning  to  wean.  Physiologically,  we  know  that  certain 
functions,  such  as  that  which  converts  starch  into  glucose,  are  but  slightly 
developed  in  the  early  months  of  life,  and  that  they  are  only  gradually 
established  during  the  first  year,  and  not,  as  a  rule,  perfected  and  in  a  con- 
dition in  which  we  can  call  upon  them  with  impunity  until  the  last  three  or 
four  months  of  that  year.  A  sign  which  aids  us  in  judging  the  progress 
of  this  development  of  the  functions  is  the  appearance  of  the  teeth,  call- 
ing our  attention  to  the  fact  that  nature  is  preparing  the  infant  to  digest 
and  assimilate  a  form  of  food  different  from  that  which  it  has  thus  far 
received  by  sucking.  The  presence  of  six  or  eight  incisors  corresponds 
usually  in  the  normally  developed  infant  to  the  full  development  of  the 
pancreatic  secretion. 

A  most  valuable  index  which  assures  us  that  we  need  not  be  anxious 
to  change  the  infant's  food  during  the  first  year  is  the  continuous  increase 
in  its  weight,  which,  with  a  general  healthy  condition,  results  from  a  nor- 
mal lactation.  We  must  allow,  however,  for  certain  variations  which  in 
"special  cases  are  as  important  as  is  the  rule  to  terminate  the  lactation  at  a 
definite  period.  The  period  of  lactation  may  be  curtailed  or  lengthened 
by  a  month  or  two  according  to  the  season  of  the  year,  the  development 
of  the  teeth,  or  the  condition  of  the  child  from  illness  or  convalescence. 
Under  such  circumstances  it  may  be  wiser  to  feed  the  infant  from  the 
breast  during  the  heated  portions  of  the  year,  and  to  wean  it  in  cool 
weather,  before  or  after  the  hot  season,  according  to  the  individual  case. 
An  interdental  period  is  also  preferable  to  a  dental  period,  on  account  of 
the  possO^le  disturbances  which  may  arise  in  the  latter  and  interfere  with 
the  proper  actions  of  the  new  functions  to  which  reference  has  been  made. 
In  these  exceptional  circumstances,  when  there  is  any  uncertainty  as  to 
the  character  of  the  milk  Avhich  the  infant  is  taking,  a  chemical  analysis 
should  be  made  at  once,  and  repeated  several  times  at  intervals  of  a  few 
days.  These  latter  months,  though  not  so  difficult  to  manage  intelligently 
as  the  early  period  of  the  infant's  life,  are  much  more  likely  to  need  care- 


FEEDING.  lo3 

fill  supervision  lliau  the  iniddlr  period,  wliicli.  from  its  usually  imiiiter- 
rupted  trauquillity,  has  been  called  the  period  of  iioriual  luilrition. 

When  oil  account  of  an  insufficient  supply  of  milk  in  tlie  mother  the 
infant  has  for  some  time  become  accustomed  to  several  meals  of  a  substi- 
tute food  daily,  the  matter  of  weaning  becomes  a  very  simple  one,  for  we 
know  that  we  have  a  food  which  will  agree  with  it ;  but  when  we  have  to 
begin  to  wean  directly  and  to  adapt  a  food  to  the  infant's  digestive  capa- 
bilities, as  in  cases  of  sudden  failure  of  the  milk  or  of  sickness  in  the 
mother,  this  procedure  becomes  much  more  intricate,  and  is  at  times 
fraught  with  considerable  danger.  It  is  in  these  cases  that  an  analysis  of 
the  milk  made  Avhen  the  mother  was  in  good  condition  often  proves  to 
be  of  great  assistance. 

The  method  of  weaning  which  we  have  adopted,  and  have  found  to  be  the 
safest  and  best  is.  provided  that  the  infant  is  thriving  or  digesting  its  mother's 
milk  well,  to  order  a  substitute  food  the  percentages  of  the  elements  of 
which  are  very  similar  to  what  the  infant  has  been  taking  from  its  mother. 
After  a  few  days,  if  this  food  is  agreeing  with  the  infant,  a  change  should  be 
made  in  the  percentages  of  the  different  elements,  with  the  object  of  gradu- 
ally combining  these  percentag-es  in  such  a  way  as  to  correspond  to  the  per- 
centages of  the  elements  of  unmodified  cow's  milk.  This  is  easily  and 
precisely  accomplished.  For  instance,  supposing  that  the  infant  is  re- 
ceiving from  its  mother  a  milk  in  which  the  percentage  of  the  fat  is  4,  of 
the  sugar  6.50,  and  of  the  proteids  2,  we  should  begin  by  giving  the  same 
percentage  of  fat  (4),  a  lesser  percentage  of  sugar  (5.50),  and  an  increased 
percentage  of  proteids  (2.25).  After  a  few  days,  if  this  milk  is  digested 
Avell  by  the  infant,  the  fat  can  be  made  4,  the  sugar  4.50,  and  the  proteids 
3.  In  a  few  more  days,  if  this  food  is  digested  well,  plain  cow's  milk, 
with  lime-water  sufficient  to  make  it  slightly  alkaline,  can  be  given.  The 
milk  which  is  now  received  from  the  farms  connected  with  the  laboratories 
is  practically  so  free  from  bacteria  that  it  need  not  be  pasteurized  in  the 
winter  months  ;  and  often,  also,  in  the  summer,  it  will  remain  fresh,  except 
in  exceptionally  warm  weather,  or  when  it  has  to  be  transported  a  long 
distance.  If  this  still  agrees  with  the  infant,  cow's  milk  without  lime-water 
can  be  given. 

Unless  under  very  exceptional  circumstances,  sudden  weaning  is  to  be 
deprecated,  though  of  course  we  must  admit  that  it  is  sometimes  done 
with  impunity.  The  safest  method,  so  long  as  we  cannot  judge  beforehand 
which  infants  will  be  likely  to  be  unfavorably  affected  by  sudden  weaning, 
is  to  take  plenty  of  time  and  gradually  ascertain  by  frequent  changes  the 
food  best  adapted  to  the  case.  The  infant  should  be  gradually  accustomed 
to  this  food,  omitting  the  breast-feedings  one  by  one,  until  finally  we  are 
sure  that  we  have  a  substitute  food  on  which  it  will  thrive.  At  the  tenth 
or  eleventh  month,  provided  that  the  weaning  of  the  infant  is  deemed 


154  PEDIATHICS. 

desii'able  al  so  early  a  [tfriod.  and  atler  having  aL-cusiomed  it  to  take  plain 
cow's  milk,  starch  in  some  form  can  also  be  given.  It  will  be  necessary 
to  determine  how  mucli  of  this  new  element  may  be  introduced  into  the 
infant's  diet,  carefully  adapting  the  amount  to  its  amylolytic  function, 
which  varies  in  ditierent  infants,  and  which  has  but  lately  arrived  at  its 
full  development.  When  these  changes  have  been  accomplished,  the 
breast  can  ^nth  safety  be  entirely  withdrawn. 

The  danger  of  injudicious  weaning  is  illustrated  by  the  following  case  : 

A  delicate  infant,  backward  in  its  development,  digesting  well,  and  a  little  over 
one  year  old,  was  suddenly  deprived  of  the  plentiful  supply  of  breast- milk  of  its 
healthy  mother  and  fed  on  oatmeal  gruel.  Vomiting  and  prostration  immediately 
began,  and  continued  until  the  oatmeal  was  omitted  and  the  breast-feeding  resumed, 
when  the  infant  began  to  thrive  again.  Three  weeks  later  the  mother,  through  igno- 
rance, suddenly  and  without  any  preparation  fed  it  again  on  oatmeal  gruel.  On  the 
following  two  days  the  infant  vomited  incessantly  and  was  much  prostrated.  Several 
changes  Avere  then  made  in  its  food,  but  the  symptoms  grew  worse,  and  the  mother, 
who  was  now  very  uneasy  about  the  infant,  again  put  it  to  her  breast,  with,  how- 
ever, this  time  a  disastrous  result,  as  her  milk  from  nervous  influences  was  so  changed 
in  its  c[uality  that  it  acted  like  a  poison  on  the  infant,  who  fell  into  a  condition  of  col- 
lapse. A  wet-nurse  with  a  healthy  infant  four  months  old  was  immediately  procured, 
and  after  several  days  of  complete  prostration  the  foster-infant  began  to  revive,  and 
later  was  gradually  weaned  without  trouble.  It  may  be  well  to  add,  for  the  encourage- 
ment of  physicians  who  have  cases  of  this  kind  to  deal  with,  that  after  the  mother's 
milk  had  poisoned  the  infant,  and  when  we  first  saw  it,  the  skm  was  gray  and  cold,  the 
foutanelle  sunken,  and  the  eyes  fixed,  yet  recovery  took  place.  Under  the  same  cir- 
cumstances equal  success  in  the  treatment  would  probably  be  obtained  by  writing  for 
a  milk  prescription  to  contain  fat  2.50,  sugar  5,  proteids  0.50.  This,  of  course, 
would  be  an  exceedingly  weak  food  for  an  infant  twelve  months  old,  but  it  would  be 
the  safest  combination  to  begin  with,  and  could  be  increased  in  strength  as  the  infant 
recovered. 

n.    DIRECT  SUBSTITUTE  FEEDING. 

"WOMEN. — When  for  any  reason  it  is  impossible  or  inadvisable  for 
the  mother  to  nurse  her  infant,  some  other  food  must  be  substituted  for 
the  maternal.  The  milk  of  another  woman  approaches  the  mother's  in 
its  chai'acteristics  most  closely,  and  should  be  obtained  unless  contra- 
indicated. 

It  is  generally  supposed  that  the  mother's  milk,  as  a  rule,  is  more 
likely  to  be  suited  to  her  infant's  digestion  than  the  milk  of  another 
woman ;  but  we  have  as  yet  too  few  cases  where  direct  investigation  by 
means  of  chemical  analysis  of  the  two  kinds  of  milk  has  been  made  to 
lay  down  actually  as  a  fact  what  we  can  merely  grant  as  a  supposition, 
that  an  idiosyncrasy  in  the  mother's  milk  will  find  an  analogue  in  her 
infant's  digestive  powers.  The  reverse  of  this  proposition  has  also  been 
held  to  be  true,  that  at  times  some  idiosyncrasy  in  the  mother's  milk  will 
make  it  radically  unfit  for  her  infant.  The  probability  is  that  analyses 
will  show  either  that  these  varieties  of  milk  are  poor  ones,  or  that  the 
infants  have  unusually  weak  digestive  powers. 


FEEDING.  155 

The  fact  that  every  mother  cannot  provide  as  good  a  milk  for  her 
infant  as  can  be  supplied  by  anotlier  woman  finds  its  analogy  in  the  ina- 
bility of  some  Jersey  cows  to  rear  their  own  calves. 

The  following  case  illustrates  how  at  times  an  idiosyncrasy  of  diges- 
tion in  the  infant  corresponds  to  some  unusual  percentage  in  its  mother's 
•  milk : 

The  mother,  a  primipara,  was  healthy,  but  of  a  highly  nervous  temperament.  The 
infant  was  thriving,  but,  as  a  measure  of  precaution  in  case  of  mammary  disturbance 
at  a  later  period  of  tire  lactation,  an  analysis  was  made  of  the  milk,  with  the  following 
result  : 

Fat 5.16 

Sugar 5.68 

Proteids 4. 14 

Mineral  matter 0. 17 

Total  solids 15. 15 

Water 84.85 

100.00 

The  report  made  by  Dr.  Harrington  in  connection  witli  this  analysis  was,  "The 
precipitated  curd  is  quite  similar  in  its  appearance  to  that  obtained  in  the  analysis  of 
cow's  milk." 

The  mother  was  advised  on  general  principles  to  take  more  exercise,  and  ten  days 
later  another  analysis  of  the  milk  was  made  : 

Fat 4.88 

Sugar 6.20 

Proteids 3.71 

Mineral  matter 0.19 

Total  solids ,      14.98 

Water 85.02 

100.00 

The  second  analysis  was  so  similar  to  the  previous  one  that,  in  conjunction  with  the 
perfect  digestion  and  health  of  the  infant,  it  was  concluded  that  this  infant  had  an  idio- 
syncrasy of  digestion  which  enabled  it  to  thrive  on  what  would  in  most  cases  cause 
extreme  disturbance.  This  view  of  the  case  proved  to  be  correct,  as  the  infant,  which 
was  under  our  care  for  a  number  of  months,  continued  to  thrive.  A  comparison  of  this 
analysis  with  that  of  the  milk  of  the  wet-nurse  on  page  158,  where  the  high  percentage 
of  proteids  caused  vomiting  of  thick  curds  by  the  infant,  will  show  a  striking  similarity 
of  the  two  milks.  There  is  no  doubt  that  in  the  majority  of  cases  a  milk  such  as  is 
represented  by  these  two  analyses  would  be  totally  unfit,  and  would  not  only  cause 
marked  indigestion  but  often  more  serious  results,  such  as  convulsions. 

The  following  case  presents  an  illustration  of  the  reverse  of  the  sup- 
position that  the  mothers  milk  will  suit  her  infant's  digestion  better  than 
the  milk  of  a  wet-nurse : 

This  infant  was  being  nursed  by  its  motlier  and  showed  continual  disturbance  of 
its  digestion.  At  times  it  would  be  constipated,  and  again  it  would  have  attacks  of 
colic  with  watery  discharges.     The  colic  was  the  most  prominent  symptom,  and  the 


]  56  PEDIATRTCS. 

child,  thouirh  looking'  fairly  well,  was  iml  paiiiinp  in  wciLrJit.  An  annlysis  of  tiie  mother's 
milk  showed  ihat  the  percentage  of  fat  was  from  2  to  8.  the  sugar  was  of  about  the 
normal  percentage,  and  the  proteids  varied  from  8  to  3.50  per  cent.  The  mother  was 
of  an  extremely  nervous  temperament  and  was  unwilling  to  carry  out  the  rules  for  the 
management  of  her  milk,  which  were  absolutely  necessary  in  order  to  reduce  the  high 
percentage  of  proteids,  which  evidently  caused  the  disturbance.  A  wet-nurse  was 
therefore  procured,  the  analysis  of  whose  milk  was  as  follo^vs  : 

Fat 2.96 

Sugar 5.78 

Proteids 1.91 

Mineral  matter 0. 12 

Total  solids 10.77 

Water 89.23 

100.00 

The  infant  on  taking  this  new  milk  ceased  to  have  colic,  but  was  more  constipated 
and  did  not  gain  in  weight.  It  was  therefore  decided  that  it  would  be  wise  to  increase 
the  percentage  of  the  fat  in  the  nurse's  milk.  This  was  done  by  giving  her  considera- 
bly more  meat  to  eat  and  making  her  take  moderate  exercise.  The  infant  within  a 
week  began  to  gain  in  weight  and  to  sleep  well,  the  bowels  ceased  to  be  constipated 
and  were  moved  naturally  every  day.  There  was  also  a  plentiful  supply  of  milk. 
Another  analysis  of  the  milk  was  then  made,  with  the  following  result : 

Fat 3.31 

Sugar 6.45 

Proteids 2.86 

Mineral  matter , 0. 16 

Total  solids 12.28 

Water 87.72 

100.00 

This  last  analysis  is  of  great  significance.  The  increase  in  the  percentage  of  the  fat 
evidently  regulated  the  faecal  movements.  The  total  solids  increased  from  10.77  to 
12.28,  and  the  plentiful  supply  of  milk  made  the  infant  gain,  especially  as  it  now  was 
digesting  perfectly.  It  was  evident  that  it  could  digest  a  milk  with  a  percentage  of  pro- 
-teids  below  2.50,  while  it  was  a  percentage  of  8  in  the  mother's  milk  which  prevented 
her  from  carrying  on  her  lactation. 

In  this  case  it  will  be  seen  that  the  milk  of  another  woman  was  far  preferable  lo 
that  of  the  mother,  and  that  the  idiosyncrasy  of  a  high  percentage  of  proteids  in  the 
mother's  milk  did  not  find  its  counterpart  in  an  idiosyncrasy  in  the  proteid  digestion  of 
her  infant. 

"WET-N'QRSES. — The  general  question  as  to  whether  a  wet-nurse 
shall  be  employed  is  one  which  is  of  serious  import,  and  must  in  each  in- 
stance be  decided  by  giving  full  weight  to  all  of  the  many  circumstances 
which  are  involved  in  the  case.  Foster-feeding,  when  all  the  conditions 
are  good,  is  superior  to  substitute  feeding.  The  reverse  of  this  statement, 
however,  must  always  be  kept  in  view,  that  a  poor  nurse,  whether  from 
temperament,  or  age,  or  general  health,  or  the  quality  of  her  milk,  had  bet- 
ter be  set  aside  when  the  conditions  are  favorable  for  a  successful  substitute 
feeding.     It  is  perhaps  better  that  the  nurse's  milk  should  correspond  in 


FEEDING.  157 

age  somewhat  nearly  to  that  of  the  infant  she  is  to  suckle,  but  a  difference 
of  some  months  in  age  may  not  be  a  contra-indication,  as  we  are  not  yet 
in  a  position  to  say  definitely  that  the  milk  differs  sufficiently  in  different 
months  to  make  this  a  reason  of  importance  in  choosing  a  nurse.  A  fee- 
ble child  will  nurse  more  easily  and  probably  have  better  care  from  a 
multipara  than  from  a  primipara.  The  preferable  age  of  the  nurse  is  be- 
tween twenty  and  thirty  years.  Her  other  recjuisites  are  a  condition  of 
good  health  and  a  cpiiet  temperament.  It  Avill  save  much  trouble  and 
often  obviate  the  frequent  necessity  for  changing  if  before  her  engagement 
we  have  made  a  chemical  analysis  of  her  milk  :  in  fact,  all  the  points  which 
have  been  already  referred  to  for  a  successfid  maternal  nursing  are  of 
equal  significance  in  the  case  of  a  wet-nurse. 

The  general  health  of  the  wet-nurse  should  be  carefully  investigated, 
as  women  suffering  from  constitutional  syphilis  or  any  chronic  disease  are 
manifestly  unfit  for  nursing.  At  the  same  time  we  should  be  careful,  un- 
less decided  symptoms  of  disease  are  present,  not  to  set  aside  the  milk  of 
a  delicate-looking  woman  until  it  has  been  analyzed.  The  wet-nurse  in 
the  case  just  descrU3ed,  whose  milk  proved  to  suit  the  infant  better  than 
did  its  mother's,  was  a  frail,  delicate-looking  woman,  but  healthy.  The 
mother,  on  the  other  hand,  was  a  large,  strong-looking  woman,  but  of  a 
very  nervous  temperament. 

Diet. — The  same  general  principles  that  have  been  stated  in  speaking 
of  the  diet  of  the  mother  should  be  applied  to  that  of  the  wet-nurse.  We 
should  be  extremely  careful  not  to  change  suddenly  the  customary  diet  of 
a  healthy  nursing  woman  on  purely  theoretical  grounds.  For  many  years 
the  mistake  was  made  of  keeping  women  on  too  low  a  diet  in  the  early 
period  of  lactation,  with  the  consequent  delay  in  the  establishment  of  a 
sufficiently  nutritious  milk-supply,  and  a  corresponding  initial  loss  of 
weight  in  their  infants.  Where,  however,  we  are  especially  likely  to  err 
is  in  permitting  a  healthy,  hard-working  wet-nurse,  accustomed  to  a  some- 
what coarse- but  nutritious  diet,  to  adopt  totally  different  habits  of  exercise 
and  a  diet  to  which  she  is  unaccustomed,  rather  than  to  have  her  continue 
her  usual  mode  of  life.  This  sudden  change  of  habits  frequently  results 
in  loss  of  health  to  the  nurse,  with  its  accompanying  deterioration  in  the 
quality  of  her  milk,  or  at  least  a  change  in  its  quality  so  as  to  make  it  an 
unfit  food  for  her  foster-child.  A  notable  instance  of  too  radical  a  change 
of  habits  was  brought  to  our  notice  by  a  case  seen  in  consultation. 

A  wet-nurse  had  been  procured  for  an  infant  ten  days  old.  An  analysis  of  her 
milk,  two  days  before  she  began  to  nurse,  is  shown  in  the  following  table.  Her  milk 
was  digested  well  for  two  or  three  weeks,  during  which  time  she  was  fed  on  an  abun- 
dance of  good  food  and  rich  milk.  The  infant  then  began  to  vomit  thick  curds  iden- 
tical in  appearance  and  toughness  ^vith  the  curds  of  cow's  milk.  Another  analysis 
was  made,  which  showed  the  amount  of  total  solids  to  be  increased  in  a  most  marked 
degree,  the  percentage  of  proteids  corresponding  far  more  nearly  to  that  of  cow's  milk 
than  to  that  of  Avoman's  milk.     The  nurse  was  then  given  plainer  food  and  skimmed 


158  PEDlATKICri. 

milk,   and  the  infant   ceasctl    lo   vdiniL      The   infiuit  and   nnrse  cuntinned   well    mid 
strong  during  the  whole  year,  the  iufanl  making  a  weekly  gain  in  weight. 

Analysis  I.  Analysis  II.  Analysis  III. 

Two  days  before        Rich  food  for    Food  regulated  and 
change  of  food.  a  month.  1"'^^  agreeing  with 

infant. 

Fat 0.7-2  5.44  5.50 

Sugar <>.T5  (1.25  6.60 

Proteids 2.53  4.01  2.90 

Mineral  matter 0.22  0.20  0.14 

Total  solids .- KX22  16.50  15.14 

Water 89.78  83.50  84.86 

100.00  100.00  100.00 

Animals. — In  parts  of  France,  notably  in  Brittany,  iniants  are  put 
directly  to  the  cow's  teats,  and  sometimes  with  good  results.  We  know  ot 
one  family  of  eight  children,  all  of  whom  were  nursed  by  the  family  cow, 
and  all  of  whom  grew  up  healthy  and  strong.  Yet  the  undesirability  of 
feeding  human  beings  directly  from  the  udders  of  animals  is  so  manifest 
that  this  method  need  not  be  discussed. 


III.  INDIRECT  SUBSTITUTE  FEEDING. 
General  Considerations. — The  resort  to  substitute  feeding  is  usually  a 
matter  of  necessity.  It  is  the  exception,  not  the  rule,  for  an  American 
mother  to  be  able  to  feed  her  infant  exclusively  on  breast-milk  for  the 
full  twelve  months.  Supplementary  feeding  generally  begins  between 
the  sixth  and  ninth  months  and  often  earlier.  The  fact  that  a  mother 
does  not  nurse  her  infant  is  due  not  so  much  to  her  unwillingness  from 
selfish  reasons,  but  to  the  fact  that  she  is  a  victim  of  the  artificial 
conditions  of  modern  life,  and  cannot  nurse  because  of  a  deficiency 
either  in  the  quantity  or  quality  of  her  milk.  The  great  majority  of 
babies  fed  on  substitutes  for  breast-milk  represents  cases  of  failure  of 
reast  feeding.  AVhereas,  in  exceptional  cases,  one  may  solve  the  prob- 
lem by  securing  a  competent  and  reliable  wet-nurse,  there  is  not  in 
this  country  a  sufficient  number  of  the  class  from  which  wet-nurses 
are  derived  to  meet  the  demand  made  by  the  enormous  number  of  infants, 
whose  mothers,  for  one  reason  or  another,  cannot  supply  their  natural 
food.  It  is,  therefore,  not  a  question  as  to  the  relative  advantages  of  breast 
and  substitute  feeding,  which  must  be  considered,  but  one  of  how  best  to 
solve  the  problem  of  feeding,  by  artificial  or  substitute  methods,  the  con- 
stantly increasing  number  of  infants  who  must  be  reared  on  the  bottle. 
There  is  little  question  that  here  in  America  the  methods  of  substitute 
feeding  have  been  more  fully  developed  along  scientific  lines  than  in  any 
other  country,  but  the  principles  of  the  modification  of  cow's  milk  and 
percentage  feeding  has  by  no  means  been  generally  adopted  by  the  profes- 
sion as  a  whole.  This  is  partly  owing  to  the  fact  that  the  subject  is 
comparatively  ne>v,  and  only  a  few  of  the  more  progressive  medical  schools 


FEEDING.  159 

have  appreciated  the  importance  of  systematicahy  instructing  their  students 
in  these  methods.  The  scientific  modification  of  milk,  and  percentage 
feeding,  are  followed  for  the  most  part  by  those  whose  practice  is  espe- 
cially in  the  line  of  children.  It  is  owing  to  the  unfamiliarity  of  the  general 
practitioner  with  these  principles  and  their  aversion  to  mastering  the 
details  of  a  somewhat  difficult  subject,  that  infant  mortality  in  the  first 
year  has  reached  such  alarming  proportions.  The  introduction  of  the 
proprietary  foods  has  not.  and  never  will,  solve  the  problem  of  substitute 
feeding  of  infants.  Fresh,  clean,  cow's  milk  must  be  the  basis  of  suc- 
cessful feeding,  and  the  knowledge  of  the  principles  by  which  such  milk 
may  be  modified  in  its  percentages  and  adapted  to  the  varying  needs  of 
human  infants,  becomes  of  vital  importance  to  tlie  welfare  of  the  race. 

A  new-born  infant,  starting  out  in  life  in  a  condition  of  perfect  health, 
can  be  successfully  reared  on  properly  modified  cow's  milk  with  almost 
the  same  degree  of  certainty  as  when  fed  from  the  breast,  but  requires 
more  care  and  attention  on  the  part  of  the  physician  and  nurse.  On  the 
other  hand,  if  the  feeding  is  not  intelligently  directed  in  the  very  beginning, 
if  gastric  and  intestinal  indigestion  are  allowed  to  develop,  and  to  interfere 
\\ith  the  physiological  growth  of  the  body,  one  often  experiences  consider- 
able difficulty  in  restoring  the  normal  function  of  digestion  and  nutrition, 
and  this  difficulty  will  be  almost  in  direct  proportion  to  the  length  of 
time  the  symptoms  of  indigestion  and  malnutrition  have  been  allowed  to 
continue. 

The  group  of  symptoms  which  for  want  of  a  better  name  is  designated 
as  difficult  digestion  occurs  most  frequently  in  the  three  periods  in  which 
the  infant's  digestion  is  likely  to  be  tampered  with, — namely,  in  the  early 
weeks  of  life,  when  experiments  are  being  made  to  determine  what  food 
will  be  best  to  start  with  ;  next,  when,  in  addition  to  the  irritation  ^arising 
from  the  beginning  of  dentition,  new  articles  of  diet  are  added  to  the 
original  food ;  and,  thirdly,  at  the  time  of  weaning,  when  there  is  often  a 
sudden  and  entire  change  in  the  character  of  the  food.  The  proper  man- 
agement of  the  first  of  these  periods  is  of  the  greatest  importance,  because 
it  is  the  time  when  the  stomach  is  in  its  most  active  period  of  growth,  and 
when  the  function  of  digestion  is  being  established,  and  following  the  rule 
of  functional  establishment,  is  in  a  state  of  unstable  equilibrium. 

We  should  recognize  the  fact  that  the  problem  of  substitute  feeding  is 
not  a  simple  one.  We  cannot  reiterate  too  often  that  the  question  which 
commojily  is  supposed  to  be  a  simple  one,  and  the  one  which  in  the  great 
majority  of  cases  is  alone  considered. — namely,  "  Which  food  shall  we  give 
to  the  infant?"' — is  a  misleading  and  insufficient  one.  The  problem  is  a 
combination  of  factors  of  which  the  kind  of  food  is  only  one,  and  we  per- 
sonally have  long  been  convinced  that  the  neglect  to  investigate  thoroughly 
and  carry  out  in  detail  the  combination  of  these  by  no  means  insignificamt 
general  factors  has  had  much  to  do  Avith  our  failures  in  substitute  feeding 
in  the  past.     If  we  are  not  on  our  guard,  an  exaggeration  of  each  single 


IGO  PEDIATRICS. 

factor  Avill  prevail,  and  by  its  influence  will  blind  us  to  much  good  work 
which  in  other  directions  has  already  been  done,  and  which  we  cannot 
afford  to  ignore. 

We  should  investigate  and  endeavor  to  copy,  each  in  its  turn,  the 
various  devices  which  nature  makes  use  of,  for  we  must  admit  that  we  are 
not  in  a  position  to  improve  on  nature's  method. 

It  is  certainly  wiser  and  more  economical  not  to  spare  expense  and 
trouble  in  arranging  the  infant's  diet,  for  the  period  of  active  growth  of  an 
organ  is  the  time  wlien  its  function  is  readily  Aveakened,  and  when  once 
weakened,  the  digestive  function  is  a  prolific  source  of  annoyance  and  ex- 
pense in  childliood  and  adolescence.  Cheap  foods  and  cheap  methods  of 
feeding,  unless  they  are  the  best  that  can  be  procured,  should  not  be  tol- 
erated in  the  early  feeding  of  infants.  We  often,  however,  see  a  food 
recommended  for  a  young  infant  because  it  is  cheap  and  easily  prepared, 
in  spite  of  the  fact  that  its  well-known  lack  of  nutritive  ingredients  should 
stamp  it  as  unfit  for  use. 

Source  of  Food. — Having  decided  to  substitute  some  food  in  place  of 
woman's  milk  for  the  infant,  we  must  decide  from  what  source  the  ele- 
ments of  this  food  shall  come.  The  food  which  approaches  most  nearly 
in  every  respect  the  product  of  tlie  human  mamma  is  that  produced  by 
the  mammae  of  other  animals.  The  reason  for  this  is  that  the  food  which 
all  mammals  provide  for  their  offspring  is  an  animal  one,  and  consists  of 
the  same  elements,  although  the  mammary  product  of  different  animals 
varies  in  the  percentage  of  these  elements  and  to  some  extent  in  the 
chemical  nature  of  its  ingredients. 

Assuming,  then,  that  average  human  breast-milk  is  the  safest  standard 
for  us  to  copy,  we  are  impressed  with  the  fact  that  although  a  vegetable 
diet  would  often  seem  far  the  easiest  method  of  procuring  nourishment 
for  young  infants,  yet  nature  has  persisted  in  providing  an  animal  one. 
We  should  therefore  in  the  first  months  not  introduce  into  our  substitute 
Miet  a  vegetable  element,  which,  as  judged  by  our  standard,  must  be  a 
foreign  element.  Milk  is  the  food  which  our  reason  tells  us  should  be 
given  to  the  young  infant,  and  a  milk  which  will  approach  as  nearly  as 
possible  to  the  average  human  milk. 

The  milk  of  various  animals  has  from  time  to  time  been  recommended 
as  the  best  substitute  for  human  milk,  the  recommendation  being  based 
on  their  analyses  approaching  more  or  less  nearly  the  composition  of 
human  milk.  The  milk,  however,  of  all  animals  has  to  be  moditied  to 
correspond  to  human  milk ;  and  when  we  begin  to  modify,  it  is  as  easy  to 
change  the  percentages  of  the  different  constituents  to  a  great  degree  as  to 
a  small. 

The  fact  that  the  milk  of  any  particular  animal  approaches  in  its 
analysis  nearly  to  that  of  the  human  breast  is  not  of  so  much  importance 
as  that  the  milk  should  be  one  which  can  be  obtained  easily  by  the  people 


FEEDING.  161 

at  large.  This  at  once  settles  the  question  that  it  is  the  milk  of  the  cow 
to  which  we  must  turn  our  attention,  even  though  cow's  milk  may  differ 
in  its  composition  from  human  milk  to  a  greater  degree  than  does  the 
milk  of  the  ass  or  the  mare,  whose  milk  approaches,  so  far  as  is  shown 
by  analyses,  most  nearly  of  that  of  all  animals  to  human  milk.  If,  how- 
ever, the  ass  and  the  mare  should  be  employed  for  dairy  purposes  to  the 
same  extent  that  the  cow  has  been,  there  is  every  reason  to  suppose  that 
their  milk  might  change  in  its  composition  and  their  comparatively  unde- 
veloped mammary  glands  increase  in  size,  just  as  has  been  the  case  with 
the  cow,  an  animal  which  for  thousands  of  years  has  been  used  for  the 
production  of  milk,  and  which  probably  did  not  in  the  beginning  give  such 
an  over-production  of  the  mammary  secretion  as  is  the  case  now.  It  is, 
then,  from  the  public  demand,  and  by  breeding,  that  cows  have  been 
made  to  produce  so  much  more  milk  than  is  necessary  for  the  support  of 
their  young.  Not  only  quantitative  but  qualitative  differences  exist  in 
animals  according  to  the  development  of  their  mammary  glands ;  and,  as 
Martiny  has  shown  in  his  collection  of  statistics  on  this  subject,  the  con- 
dition Avhich  determines  the  quantity  and  the  quality  of  the  milk  depends 
on  the  development  of  the  organ  which  produces  it. 

A  further  exemplification  that  cow's  milk  is  practically  the  universal 
source  of  the  substitute  food-supply  for  infants  in  most  civilized  commu- 
nities is  the  fact  that  the  various  foods,  patent  or  not,  all  depend  for  their 
basis  on  cow's  milk,  and  that  without  this  addition  of  milk  they  would 
show  but  an  insignificant  percentage  of  many  of  the  most  important  in- 
gredients of  the  food.  Logically  we  should  not  speak  of  the  various  foods 
as  such,  but  merely  as  adjuvants  to  cow's  milk.  If  this  is  thoroughly 
understood,  much  misapprehension  regarding  the  apparently  successful 
results  of  innumerable  foods  will  be  done  away  with. 

Another  reason  for  using  cow's  milk  in  preference  to  all  others  is 
owing  to  the  fact  that  the  cow  can  be  kept  under  more  strict  control  than 
any  other  mammal. 

If  human  milk  is  to  be  taken  as  a  guide  in  substitute  feeding,  it  will  be 
instructive  to  observe  how  closely  these  other  varieties  of  milk  approach 
it  in  composition,  always  allowing  that  human  milk  varies  and  that  the 
milk  of  all  animals  also  varies.    This  is  illustrated  in  the  following  table  : 

TABLE  38. 
Showing  Variations  in.  Composition  of  Milk  of  Different  Animah. 

Percentage  Mineral  Total 

of  Fat.  Sugar.         Proteids.        Matter.  Solids. 

Human  Milk 4.00  7.00  ]  .50  0.20  12.70 

Cow's  Milk 4.00  4.75  3.50  0.70  12.95 

Goat's  Milk 4..30  4.00  4.70  0.60  13.50 

Mare's   Milk 1.09  6.65  1.89  0.31  9.94 

Ass's  Milk 1.60  6.10  2.20  0.50  10.04 

It  is  evident  from  these  figures  that  the  difference  in  the  milks  is  not  so 
much  in  the  amount  of  total  solids  as  in  the  relative  proportion  of  fats, 

11 


162  PEDIATRICS. 

sugar  and  proteids.  Not  one  of  them  approaches  at  all  closely  to  the  com- 
position of  human  milk,  in  comparison  M'ith  which  both  cow's  and  goat's 
milks  are  low  in  sugar  and  high  in  proteids  ;  while  mare's  milk  and  ass's 
milk  are  very  deficient  in  fats.  If,  therefore,  human  milk  is  to  be  im- 
itated in  its  composition  in  substitute  feeding,  some  form  of  modification 
will  be  necessary. 

THE  CO"W. — Having  chosen  the  cow  for  our  primal  milk-supply,  we 
must  next  consider  whether  any  special  breed  is  better  adapted  than 
others  for  accomplishing  our  purpose.  To  do  this  we  should  first  examine 
chemically  and  microscopically  the  elements  of  the  milk  of  those  breeds 
which  can  be  employed  best  throughout  the  civilized  world.  It  has  been 
found  that  the  finer  breeds  of  cows  from  the  Channel  Islands  are  more 
liable,  when  transported  from  their  home  to  countries  where  the  climate 
is  more  severe,  to  contract  diseases,  such  as  tuberculosis,  than  are  the 
animals  represented  by  the  Durham,  Devon,  Ayrshire,  and  Holstein  breeds. 

Among  the  breeds  of  cows  which  should  be  used  for  infant  feeding  at 
the  farms  connected  with  the  laboratories  are  the  following: 

The  Durham,  or  Shorthorn,  represents  the  best  type  of  cow  for  this 
purpose.  She  has  great  constitutional  vigor,  great  capacity  for  food,  a  per- 
fect digestion,  a  placid  temperament,  and  yields  a  large  quantity  of  rich  milk. 

Another  breed,  the  Devon,  has  the  same  general  characteristics  as  the 
Durham.  The  cows  are  gentle  and  vigorous,  and  give  a  moderate  cjuantity 
of  milk  of  medium  quality. 

Another  breed  is  the  Ayrshire,  Avhose  constitutional  vigor  is  great,  but 
whose  temperament  is  nervous.  The  cows  are  not  so  hardy  as  the  Dur- 
ham, but  are  very  free  from  disease.     They  yield  a  large  supply  of  milk. 

Another  breed  which  is  of  a  thorough  dairy  type  is  called  the  Holstein- 
Priesian.  This  cow  represents  the  most  perfect  milking  animal  known, 
having  every  characteristic  of  a  cow  suitable  for  an  infant's  milk-supply, 
but  her  milk  is  so  light  in  its  total  solids  that  it  is  not  so  profitable  as 
^the  other  breeds.  She  yields  a  larger  quantity  of  milk  than  any  other 
known  breed,  although  the  analysis  shows  it  to  be  poorer  in  quality. 

Another  breed  is  called  the  Brown  Swiss  grade.  The  cows  are  very 
vigorous,  healthy,  and  docile,  and  yield  a  fair  supply  of  milk  of  about  the 
richness  of  the  Devon. 

Finally,  we  can  make  use  of  the  little  Bretonne  cow,  known  all  over 
Europe  as  the  '•  cow  for  the  family."  Cows  of  this  breed  have  all  the 
characteristics  of  the  good  domestic  cow  whicli  have  already  been  men- 
tioned. They  produce  a  medium  amount  of  milk,  large,  however,  in  pro- 
portion to  their  size. 

The  variation  in  the  composition  of  milk  according  to  the  breed  is 
shown  in  the  following  table,  compiled  from  average  analyses,  by  Mr.  Gor- 
don of  the  Walker-Gordon  Laboratory.  More  recent  analyses  show  nearly 
one-half  of  one  per  cent,  more  of  sugar  and  less  of  proteids  than  given  in 
the  following  table : 


FEEDING. 


168 


TABLE  39. 

Shovnng  Variations  in  the  Composition  of  Cow's  Milk,  According  to  tlte  Breed. 

Durham  or  Holstein- 

Shorthorn.  Devon.  Ayrshire.  Friesiaii. 

Fats   4.04  4.09  .3.89  2.88 

Sugar 4..35  4.32  4.41  4.38 

Proteids * 4.17  4.04  4.01  3.99 

MineralMatter 73  .76  .73  .74 

Total  Solids  13.28  13.21  13.04  11.94 

AYater 86.72  86.79  86.96  88.06 

Daily  quantity Large.  ^Moderate.       Large.  Very  large. 

Brown  Common  American 

Swiss.  Jersey.  Xative.  Grade. 

Fats 4  00  5.21  3.69  4.01 

Sugar 4.30  4.52  4.35  4.36 

Proteid;^ 4.00  .3.99  4.09  4.06 

Mineral  Matter 76  .71  '    .73  .74 

Total   Solids 13.06  14.43  12.86  13.17 

AVater 86.94  85.57  84.14  86.83 

Daily  quantity ^Moderate.       Large.  ^loderate.        Moderate. 

Analyses  of  milk  from  Guernsey  cows  closely  approach  those  of  the 
Jersey  cow. 

The  miportance  of  the  selection  of  the  herd  in  substitute  feeding 
depends  not  so  much  upon  the  differences  in  gross  composition  of  the 
milks,  as  upon  other  considerations.  The  volatile  glycerides  for  example, 
which  are  present  in  very  small  proportion  in  human  milk,  are  consider- 
ably greater  in  Jersey  and  Guernsey  milk  than  in  that  of  the  commoner 
breeds  of  cows,  such  as  the  Holsteins.  They  increase  decidedly  the  diffi- 
culty of  digestion.  Moreover,  the  fat  corpuscles  in  Jersey  milk  are  much 
larger  than  those  of  Holstein  milk  and  are  less  easily  emulsified.  The 
volatile  glycerides  do  not  exist  in  the  mammas  but  are  formed  in  the  milk 
soon  after  the  milking.  In  Guernsey  and  Jersey  milk  this  change  occurs 
more  quickly  than  in  the  other  varieties.  Modifications  made  up  from 
Jersey  or  Guernsey  milk,  therefore,  are  less  likely  to  maintain  their 
emulsion  and  more  likely  to  show  an  excess  of  volatile  glycerides.  For 
these  reasons  there  is  a  strong  theoretical  argument  against  their  use  in 
infant  feeding,  and  in  practice  it  is  found  to  be  much  less  suitable  than  the 
milk  of  common  breeds.  Holsteins,  Durham  and  Ayrshires  should  always 
be  selected  in  preference  to  the  higher  grades.  The  mixed  milk  of  a  herd 
is  less  variable  in  its  composition  than  that  of  a  single  cow,  and  for  this 
reason  it  is  to  be  preferred  for  the  purposes  of  infant  feeding. 

Some  of  the  marks  which  distinguish  the  breeds  of  cows  best  adapted 
for  infant  feeding  are  :  {a)  constitutional  vigor,  (6)  adaptability  to  acchmat- 
ization,  (e)  notable  ability  to  raise  their  young,  (c/)  freedom  from  intense 
inbreeding,  (e)  a  distinctly  emulsified  fat  in  the  milk,  (/")  a  preponderance 
in  the  fats  of  the  fixed  glycerides  over  the  volatile  glycerides. 

Such  breeds  as  the  Jersey,  Gaernsey,  and  many  others  in  which 
intense  inbreeding  has  been  carried  on  and  in  which  acclimatization  has 


164  PEDIATIUCS. 

not  been  perfected,  should  not  be  used  for  infants  and  young  children. 
These  breeds,  of  course,  do  not  represent  all  of  those  available  for 
substitute  feeding,  for  we  may  mention  many  others  equally  good  each 
in  its  country.  For  example,  the  Kerry  of  Ireland,  the  Red  Polled  of 
England,  the  Dutch  Belted  and  the  Flemish,  also  the  Flamaude  and  the 
Cotentine  of  France,  the  Norman  breed  of  Normandy,  besides  the  Brown 
Swiss  just  spoken  of,  and  the  Simmenthal,  sometimes  called  Bernese, 
of  Switzerland,  also  the  Chianina  of  Italy,  and  the  Allgauer  of  Germany. 
The  native  cow  of  this  country,  the  "  Red  Cow,*'  through  many  gen- 
erations of  neglect  and  exposure  in  winter,  has  undoubtedly  acquired 
an  impaired  digestion  and  does  not  respond  readily  to  appropriate  changes 
of  food. 

Care  of  the  Cow. — A  cow  whose  milk  is  to  be  used  for  purposes  of 
infant  feeding  should' be  properly  housed  and  well  cared  for,  as  the  do- 
mestic cow  is  an  animal  peculiarly  sensitive  to  her  surroundings,  and  her, 
product  is  correspondingly  liable  to  be  thrown  out  of  equilibrium.  The 
cow  is  liable  to  contract  diseases  communicable  to  man,  and  especially  to 
infants,  and  she  is  a  ready  vehicle  for  the  transmission  of  obscure  affec- 
tions of  a  septic  character.  Her  surroundings  are  such  as  to  favor 
infection,  and  her  attendants  are  often  the  means  of  conveying  to  the  milk 
many  of  the  transmissible  diseases,  such  as  scarlet  fever,  diphtheria,  and 
tuberculosis. 

The  ordinary  cow  is  allowed  to  range  over  wide  pastures  which  are 
sometimes  overflushed  with  herbage  and  sometimes  parched  by  drought, 
and  which  nearly  always  contain  noxious  weeds,  which  she  seems  eagerly 
to  seek.  Again,  she  is  forced  to  drink  from  stagnant  pools  and  polluted 
streams,  and  at  other  times  suffers  for  want  of  water  for  many  hours  to- 
gether. She  is  also  frequently  exposed  to  storms.  Cows  cared  for  in  this 
way  are  not  those  which  provide  the  best  milk  for  substitute  feeding. 
JThese  are  the  adverse  conditions  which  surround  the  ordinary  cow  during 
the  summer.  In  the  winter  she  is  crowded  in  the  stifling  atmosphere  of  a 
close  barn  with  the  manure  of  the  whole  winter  kept  underneath  the  floor 
on  which  she  stands.  Her  head  is  usually  confined  in  a  narrow  stall. 
The  fodder  intended  for  the  winter's  supply  is  kept  above  her  head,  and 
is  continuously  contaminated  by  the  foal  odors  of  the  barn.  She  is  turned 
out  to  the  watering-trough  at  periodical  intervals.  Thus  she  cannot  be 
said  to  be  cared  for  in  a  manner  conducive  to  the  equable  function  of  her 
mammary  gland  or  for  the  production  of  clean  milk. 

For  cows  to  be  used  for  the  purpose  of  infant  feeding  a  barn  is  needed 
where  each  cow  sliall  have  at  least  twelve  hundred  cubic  feet  of  fresh  air. 
The  food  should  be  kept  where  it  cannot  be  contaminated.  The  manure 
should  be  as  carefully  removed  from  the  barn  as  if  it  were  a  human  dwell- 
ing. The  cow  should  have  freedom  for  her  head  and  limbs  in  wide  stalls. 
Large,  dry,  sunny  exercise-yards  should  be  provided  for  her.  Her  food 
should  always  be  brought  to  her  and  selected  with  great  care.     Pure 


FEEDING.  1(35 

water  should  be  provided,  and  suitable  cups  or  troughs  containing  running 
water  should  be  in  her  stall.     The  bedding  should  be  fregh  and  free  from 
mould  or  from  any  soil  productive  of  bacterial  growth.     Methods  should 
be  used  to  get  rid  of  all  the  usual  foul  odors  and  free  ammonia  so  com- 
monly produced  in  barns.      Cows  should  be  carefully  guarded  against 
fright,  the  worrying  of  dogs,  and  unusual  excitements  of  all  kinds,  which 
cause  serious  disturbance  of  the  lacteal  functions  of  domesticated  cows,  in 
contradistinction  to  those  of  cows  in  a  more  natural  condition,  as,  for  in- 
stance, the  cows  in  a  semi-wild  state  on  the  plains  of  Montana,  Texas, 
Australia,  and  the  Pampas  of  Soutli  America.     Excitement  does  not  ap- 
parently injure  the  lactation  of  these  cows,  wliile  it  inevitably  throws  out 
of   equilibrium  the  milk  of  the  well-cared-for  dairy  cow.     If  the  same 
care  should  be  applied  to  regulating  tlie  woman's  life  as  can  be  employed 
in  the  barn,  we  should  encounter  fewer  difficulties  in  human  breast-feed- 
ing.   The  feeding  of  the  cows  should  have  for  its  object  the  production  of 
an  even,  nutritious,  digestible  milk  and  the  careful  avoidance  of  over- 
stimulation of  the  lacteal  secretion.     The  exact  chemical  analysis  of  any 
one  ration  used  for  feeding  cows  for  our  purpose  must  be  carefully  consid- 
ered in  accordance  with  the  ratio  of  the  digestible  nutrients  of  the  fooa, 
and  this  must  of  course  be  arranged  practically  from  the  recognized  food 
tables.     A  great  variety  of  food  is  necessary  in  feeding  cows,  but  in  the 
transition  from  green  foods  to  dry,  or  the  reverse,  much  care  is  needed  to 
graduate  the  change,  as  disturbance  in  the  equilibrium  of  the  mammary 
gland  is  rapidly  folio w^ed  by  injurious  effects  on  the  consumer.     In  past 
times,  before  we  could  rely  as  Ave  do  now  on  this  carefully  managed  change 
of  rations,  the  spring  of  the  year  with  its  flush  pasturage  and  the  fresh 
grass  following  the  autumn  rains  were  fruitful  sources  of  infantile  digestive 
disturbance  in  our  nursery  practice. 

All  these  hnks  in  the  chain  which  constitutes  a  successful  substitute 
feeding  are  of  great  importance.  The  cows  must  be  kept  clean  by  groom- 
ing and  the  necessary  washing,  the  precaution  always  being  taken  to 
rub  the  moistened  parts  dry.  The  milkers  should  be  dressed  in  clean, 
freshly  sterilized  white  suits  and  caps.  Their  hands  and  arms  should  be 
thoroughly  scrubbed  before  milking.  The  hands  in  milking  should  be 
kept  dry.  The  milking-stools  should  be  made  of  metal  so  that  they  can 
be  sterihzed.  The  milk  should  be  drawn  with  some  force,  simulating  the 
action  of  the  calf,  and  at  each  milking  every  drop  of  milk  should  be  drawn 
out.  The  milk  should  be  drawn  into  sterilized  pails  and  carried  imme- 
diately from  the  barn  to  the  milk-house,  which  should  be  a  sufficient  dis- 
tance from  the  barn  to  be  free  from  odors.  No  means  yet  known  to 
science  can  prevent  some  few  bacteria  coming  into  the  milk  during  the 
milking-time,  though  it  is  possible  to  reduce  the  number  so  greatly  as  to 
make  the  milk  practically  sterile  for  the  purpose  of  infant  feeding,  par- 
ticularly if  the  second  half  of  the  product  of  the  udder  alone  is  used  and 
milked  into  sterile  tubes.     The  first  half  probably  contains  many  bacteria, 


1(^6  PEDIATKICS. 

which,  eiitei'iii^^  from  without,  have  reached  the  lo\\cr  portion  of  tlie  teat. 
The  major  part  of  the  bacteria  present  in  the  milk  are  such  as  cause 
the  usual  acid  fermentation  which  we  recognize  in  the  common  souring  of 
milk,  but  there  are  many  species  of  bacteria  which  ought  to  be  prevented 
from  gaining  access  to  the  milk,  arising  from  mouldy  hay,  straw,  or  fodder, 
partially  decayed  roots,  and  the  natural  decay  of  the  wood-work  of  the 
barn  and  adjoining  buildings.  These  latter  varieties,  which  are  found  to 
be  especially  inimical  to  the  preparation  of  substitute  foods,  cause  in  some 
cases  the  alkaline  fermentation  and  other  abnormal  conditions  of  milk. 
Every  barn  apparently  has  its  own  set  of  bacteria,  and  the  flora  in  Amer- 
ica do  not  exactly  resemble  the  analogous  European  species  which  have  so 
often  been  described. 

The  bacteria  which  are  found  in  cow's  milk  do  not  necessarily  come 
from  external  sources,  whether  they  be  of  the  cow  herself  or  of  her  sur- 
roundings, but  may  also  come  from  some  part  of  the  milk  tract  between 
the  udder  and  the  end  of  the  teat.  These  conclusions,  it  may  be  said,  are 
made  with  reference  to  healthy  cows. 

Infectious  mammitis,  to  some  extent,  seems  clearly  to  be  carried  by  the 
hands  of  the  milkers  from  cow  to  cow.  This  also  points  to  the  fact  that 
bacteria  may  find  their  way  to  the  ducts  through  the  teats. 

Tuberculin  Test  of  Cows. — It  is  very  important  that  certain  precau- 
tions should  be  taken  to  prevent  the  use  of  cows  which  are  affected  with 
tuberculosis.  It  is  probable  that  three  per  cent,  of  the  cows  whose  milk 
is  used  for  food  are  tuberculous.  Where  tuberculosis  is  developed  to  such 
a  degree  in  the  cow  as  to  be  dangerous  to  the  consumer  of  the  milk,  the 
disease  can  be  usually  detected  by  a  skilful  veterinarian  by  means  of  the 
physical  examination  Avhich  is  employed  in  cows.  But,  as  it  is  a  disputed 
question  at  present  as  to  when  the  milk  of  a  tuberculous  cow  becomes 
affected,  it  is  wiser  to  adopt  all  measures  of  precaution  known  to  science. 
Of  these  measures  the  one  which  is  most  efficacious  in  detecting  even  the 
^/Hnrcipient  stages  of  tuberculosis  is  the  "tuberculin  test."  All  the  cows  in 
use  at  the  farms  of  the  milk-laboratories  are  subjected  to  this  test,  and 
unless  a  negative  reaction  is  obtained  they  are  isolated  from  the  rest  of 
the  herd. 

Care  of  the  Milk. — ^After  the  cows  are  milked,  the  milk  should  be 
carried  quickly  from  the  cow  to  the  milk-house,  which  should  be  at  least 
a  hundred  yards  from  the  barn  and  completely  isolated  from  all  other 
buildings.  To  prevent  the  milkers  from  going  into  the  milk-room,  the 
milk  at  the  farms  connected  with  the  milk-laboratories  is  poured  by  means 
of  a  block-tin  pipe  through  the  wall  of  the  milk-room  into  a  large  ice-lined 
block-tin  tank,  which  is  also  the  mixer  for  the  milk  of  the  entire  herd.  In 
the  space  of  four  minutes,  by  means  of  an  ice-jacket,  the  milk  is  cooled 
from  33.88°  C.  (93°  F.)  to  below  4.44°  C.  (40°  F.).  This  is  to  rapidly 
remove  the  heat,  which  is  conducive  to  bacterial  growth.  The  milk 
passes  through  eight  thicknesses  of  sterilized  gauze  on  its  way  to  the  tank. 


FEEDING.  167 

The  milk-room  is  practically  clean  from  a  bacteriological  stand-point,  for 
the  walls  and  floor  are  kept  wet  with  clean  water,  and  all  dust  is  ex- 
cluded. The  air  which  enters  the  milk-room  is  washed  with  sterilized 
water  as  it  enters.  Part  of  the  milk  is  then  passed  through  the  separator, 
while  part  is  drawn  into  sterile  jars  for  transportation.  No  one  is  allowed 
to  enter  the  milk-room  except  the  man  in  charge,  and  he  is  carefully 
trained  to  be  absolutely  clean  in  person,  taking  special  care  of  his  hands, 
face,  and  hair.  While  in  the  milk-room  he  wears  freshly  sterilized  white 
clothes.  In  the  milk-room  the  jars  are  sealed,  packed  in  ice,  and  in  a  few 
hours  delivered  at  the  laboratory. 

After  milk  has  been  treated  with  these  precautions,  we  have  had  re- 
peated bacteriological  examinations  made  on  its  arrival  at  the  laboratory, 
with  the  uniform  result  that  it  has  proved  to  be  comparatively  sterile, 
and  at  times  it  has  contained  either  no  colonies  of  bacteria  or  only  one 
or  two. 

No  antiseptic  can,  without  danger  to  the  infant,  be  used  about  the 
cow,  while  all  the  mechanical  devices  heretofore  tried  to  take  the  place 
of  manual  milking  have  inevitably  tended  to  impair  the  lacteal  function 
of  the  udder. 

CHEMISTRY  OF  COW'S  MILK. — We  have  spoken  of  milk  in 
general,  and  of  certain  points  in  connection  with  the  chemistry  of  human 
milk  in  considering  the  subject  of  maternal  feeding.  In  indirect  substitute 
feeding^  which  involves  a  consideration  of  the  principles  governing  the 
modification  of  cow's  milk,  it  is  of  the  first  importance  that  the  physician 
should  acquaint  himself  with  the  chemical,  physiological,  and  bacterio- 
logical characteristics  of  the  food  with  which  he  is  dealing.  The  failure  to 
appreciate  the  importance  of  such  a  knowledge  is  responsible  for  much  of 
the  ill-founded  criticisms  of  those  who  oppose  the  methods  of  percentage 
feeding,  and  the  failure  to  obtain  satisfactory  results  by  those  who  have 
attempted  to  adopt  percentage  feeding  without  understanding  its  funda- 
mental principles.  It  is,  therefore,  well  worth  our  while  to  consider  in 
more  or  less  detail  certain  points  bearing  on  the  chemistry  of  cow's  milk. 

The  Composition  of  Cow's  Milk  and  Its  Digestion. — Milk  consists  of  an 
emulsion  of  fat  in  minute  subdivision  suspended  in  the  milk-plasma  which 
consists  of  milk-sugar,  or  lactose,  proteids,  extractives,  mineral  matter  and 
water.  It  is  therefore  apparent  that  all  the  great  subdivisions  of  foodstuffs 
are  represented,  that  is  fats,  carbohydrates,  proteids,  mineral  matter  and 
water. 

The  analyses  of  cow's  milk  by  French  and  German  chemists,  as  well  as 
by  many  English  and  American  investigators,  show  varying  results,  which 
serve  to  emphasize  the  fact,  which  cannot  be  too  strongly  impressed,  that 
the  composition  of  milk  of  large  herds  of  cows,  as  well  as  of  individual 
cows,  varies  sometimes  within  wide  limits  of  any  average  that  one  may  at- 
tempt to  establish.  These  variations  depend  upon  the  breed  of  the  cow, 
the  methods  of  feeding,  the  health  of  the  animal,  the  season  of  the  year,  the 


168  PEDIATRICS. 

stage  of  lactation,  the  length  of  time  between  two  successive  milkings,  the 
portion  of  the  milk  withdrawn  from  the  udder,  and  many  other  conditions. 
In  working  out  a  system  of  milk  modification  for  laboratory  and 
home  use.  it  is  necessary  that  some  standard  analysis  be  adopted  for  the 
various  materials  used  in  the  modification  of  milk,  and  we  have  therefore 
accepted  the  following  average  composition  of  whole  milk,  fat-free  milk, 
whey  and  creams,  which  are  based  upon  the  results  obtained  by  the 
analyses  of  a  large  number  of  samples  taken  from  the  many  different  herds 
which  supply  the  milk-laboratories  : 

TABLE  40. 

Analysis  of  Coic's  Milk. 

Per  cent. 

Fats , 4.00 

Milk-sugar  (lactose ) 4. 75 

Total  proteids 3.50 

Caseinogen 2.66 

Whey-proteids  (including  nitrogenous  extractives) 0.84 

Mineral  matter 0.75 

Total  solids 13.00 

Water 87.00 

Analysis  of  Fat-free  Milk. 

Fats ' '. 0.05 

]\Iilk-sugar 5.00 

Total  proteids 3.55 

Analysis  of  Whey. 

Fats *....' 0.00 

Sugar 5.10 

Whey-proteids  (including  nitrogenous  extractives) 0.90 

If  whey  is  made  from  fat-free  milk  the  whey-proteids  average  1.1%  (Adriance). 

Analysis  of  Creams. 

Fats 8.00        10.00        12.00        16.00        20.00        32.00 

Sugar 4.55  4.45  4.35  4.20  3.95  3.40 

Total  proteids 3.35  3.27  3.20  3.05  2.90  2.50 

The  composition  of  16  and  32  per  cent,  creams  is  based  upon  actual 
analyses;  the  composition  of  8, 10, 12  and  20  per  cent,  creams  is  calculated 
on  the  bases  of  the  composition  of  milk,  16  and  32  per  cent,  creams. 

The  following  analyses  of  cereal  decoctions  were  made  for  us  by  Mr. 
F.  W.  Howe,  showing  the  composition  of  barley  and  oat  jellies  when  made 
with  2  and  3  ounces  of  the  flour  to  one  quart  of  water,  cooking  for  one- 
half  hour  and  adding  enough  water  to  make  a  full  quart.  With  these 
analyses  known  one  can  calculate  for  percentages  of  starch  as  readily  as 
for  those  of  other  ingredients.     (See  page  191.) 


TABLE  41. 

Analysis  of  Cereal  Decoctions. 

Solids.            Fats. 

Proteid. 

Starch. 

Ash. 

Oat. 

— 2  oz 

3.52             .08 

.41 

2.99 

.03 

3  oz 

5.21             .11 

.47 

4.58 

.05 

Bar] 

ley. — 3  oz 

5.19             .03 

.68 

4.43 

.04 

2  oz 

3.48            .02 

.54 

2.88 

.03 

FEEDING.  169 

Reaction. — Perfectly  fresh  milk  is  amphoteric,  but  cow's  milk  is  rela- 
tively more  acid  than  human  milk.  The  acidity  is  due  to  the  presence  of 
phosphates  ;  the  alkalinity  to  the  presence  of  alkaline  carbonates. 

Specific  Gravity. — The  specific  gravity  varies  from  1.028  to  1.034.  It 
increases  very  slightly  for  a  few  hours,  due  to  molecular  modifications 
of  the  casein.  It  is  dependent  upon  the  presence  of  solids  not  fat  which 
are  in  solution,  which  tend  to  raise  the  specific  gravity,  and  on  the  fat 
itself,  which  by  virtue  ot  its  being  lighter  than  water,  tends  to  lower 
the  specific  gravity.  It  is  lowered  by  the  addition  of  cream  or  water,  and 
is  raised  by  the  removal  of  the  cream. 

Milk-Fats. — The  fats  of  milk  exist  entirely  in  the  form  of  the  fat 
globules  suspended  in  the  plasma.  These  globules  vary  greatly  in  size, 
and  are  probably  purely  fat.  The  percentage  of  fat  in  milk,  as  seen  above, 
varies.  Four  per  cent,  is  taken  as  a  fair  average  of  good  milk.  The  non- 
volatile milk-fat  consists  chiefly  of  palniatin,  stearin,  and  olein,  the  source 
of  butter.  The  volatile  fats  are  composed  of  butyric  acid,  caproic  acid, 
and  a  small  trace  of  myristic  acid,  caprylic  acid,  capric  acid,  lauric  acid 
and  arichidic  acid.  (See  page  163.)  Lecithin,  cholesterin  and  a  yellow 
coloring  matter  are  also  present. 

Milk-Plasma. — Milk-plasma  contains  in  solution,  or  pseudo-solution, 
the  remaining  constituents  of  milk,  that  is  the  milk-sugar  or  lactose,  the 
proteids,  caseinogen,  lactalbumin,  lactoglobulin,  the  fermeat  galactase, 
and  the  mineral  matter.  The  proteid  substances  are  of  complex  composi- 
tion, containing,  C,  0,  N,  H,  P,  and  S,  but  the  composition  of  the  proteid 
molecule  is  not  known.  The  molecule  of  the  principal  proteid,  casein, 
exists  in  chemical  combination  with  calcium  and  is  therefore  sometimes 
spoken  of  as  calcium-casein.  Certain  extractives  are  also  present,  that  is, 
faint  traces  of  urea,  creatin,  creatinin,  xanthin,  lecithin,  cholesterin  and 
citric  acid.    The  gases  of  milk  consist  chiefly  of  COj,  N,  and  traces  of  0. 

Milk-Sugar  or  Lactose. — Lactose  is  found  in  nature  in  milk  alone,  but 
has  been  detected  pathologically  in  the  urine  of  pregnant  w^omen.  When 
heated  to  170°  to  180°  C.  it  is  converted  into  lactocaramel,  but  when 
heated  in  solution  it  begins  to  undergo  decomposition  at  70°  C.  (158°  F.), 
W'hich  is  a  point  of  some  significance  in  connection  with  the  subject  of 
sterilization  of  milk  in  infant  feeding. 

Regarding  the  kind  of  sugar  which  should  be  used  in  making  up  a  sub- 
stitute food,  we  have  certain  cjuestions  to  consider  which  would  seem  to  be 
important.  Cane-sugar  has  been,  and  still  is,  a  favorite  form  with  which  to 
regulate  this  part  of  the  solid  constituents  of  the  food.  The  reasons  given 
for  using  it  have  been  its  preservative  qualities,  as  seen  in  the  manufacture 
of  condensed  milk,  and  the  theory  that  it  is  not  liable  to  set  up  excessive 
so-called  lactic  acid  fermentation,  with  its  consequent  disturbance  of  diges- 
tion, as  has  been  supposed  to  be  the  case  with  milk-sugar.  Cane-sugar  in 
a  concentrated  form,  as  it  is  found  in  condensed  milk,  seems  to  act  as  a 
preservative,  but  when  it  is  diluted,  as  in  its  administration  to  the  infant, 


170  PEDlATr.ir?:. 

cane-sugar  ferments  very  readily,  and  in  tliis  respect  has  no  advantage 
over  milk-sugar.  Reasoning  from  analogy,  we  should  say  that  as  milk- 
sugar  is  the  only  form  of  sugar  found  in  the  milk  of  mammals,  it  is  there  for 
some  good  purpose,  and  that  it  is  needed  for  the  accomplishment  of  some 
process  which  takes  place  after  the  food  has  been  swallowed.  Both  cane- 
sugar  and  milk-sugar  are  converted  into  glucose  either  in  the  intestine  or 
in  the  process  of  absorption  from  the  intestine.  There  seems,  however, 
to  be  some  difference  in  the  degree  to  which  they  can  be  used  for  pur- 
poses of  nutrition  before  they  are  converted  into  glucose.  So  far  as  is 
known,  whetlier  in  plants  or  in  animals,  cane-sugar  is  merely  a  reserve, 
and  cannot  be  used  directly  for  nutrition.  Milk-sugar,  on  the  other  hand, 
is  probably  not  merely  a  reserve,  but  may  possilDly  be  utilized  in  the  econ- 
omy also  for  nutrition.  Thus,  Bernard  has  showai  that  seven  grains  of 
milk-sugar  dissolved  in  an  ounce  of  water  could  be  injected  under  the 
skin  of  a  rabbit  ^^1thout  the  subsequent  appearance  of  sugar  in  the  urine, 
while  under  the  same  conditions  and  in  the  same  amount  cane-sugar  was 
found  to  be  eliminated  as  foreign  matter  by  the  kidneys. 

Milk-sugar  undergoes  no  direct  alcoholic  fermentation  except  when  ex- 
posed to  certain  unusual  ferments,  but  it  changes  readily  to  lactic  acid  in 
the  presence  of  nitrogenous  ferments.  The  lactic  acid  fermentation  may 
be  cliecked  by  heating  the  milk.  Cane-sugar,  on  the  other  hand,  easily 
undergoes  alcoholic  fermentation,  but  changes  to  lactic  acid  less  readily 
than  milk-sugar.  Cane-sugar,  moreover,  takes  on  the  butyric  acid  fer- 
mentation more  readily  than  does  milk-sugar.  The  bacillus  lactis  aerogenes 
i^Escherich)  is  present  in  normal  digestion,  and  acts  on  the  milk-sugar  to 
produce  an  organic  acid  wtdch  drives  out  the  more  noxious  forms  of 
bacteria,  wliich  by  their  presence  would  interfere  A^itli  normal  digestion. 
When  milk-sugar  is  converted  into  glucose  and  galactose,  we  physiologi- 
cally have  a  gradual  conversion  into  lactic  acid,  which  may  aid  in  the 
dia-estion  of  the  proteids,  thus  gi^-ing  us  a  very  valuable  addition  to  tlie 
means  at  our  command  tor  rendering  modified  cow's  milk  digestible. 

Jeffries  says,  in  reference. to  the  different  actions  of  the  various  kinds  of 
sugar  in  the  digestive  tract,  that  it  is  important  to  note  that  starch,  dex- 
trin, inulin,  cane-sugar,  and  dextrose  afford  material  for  the  butyric  acid 
fermentation,  while  milk-sugar  does  tliis  only  after  completed  hydration. 

Escherich,  in  speaking  of  Brieger's  bacillus,  says,  "  Milk  is  coagulated 
\\ith  sour  reaction  first  after  several  days  (eight  to  ten)  at  tlie  body  tem- 
perature. With  exclusion  of  air  this  bacillus  cannot  grow  either  in  milk 
or  milk-sugar  solution,  but  will  in  grape-sugar.  We  thus  see  that  the 
milk-sugar  offers  less  danger  of  the  butyric  acid  ferment,  which  we  know 
makes  mucli  trouble  at  times  in  the  body,  and  that  under  certain  con- 
ditions of  the  intestine  it  should  be  exempt  from  the  assaults  of  Brieger's 
bacillus. 

"When  we  consider  that  by  means  of  heat  we  can  practically  put  an 
end  to  the  lactic  acid  fermentation,  which  may  have  begun  to  act  upon  the 


FEEDING.  171 

milk  before  it  enters  the  stomach,  it  would  seem  that  we  are  justified,  on 
both  physiological  and  bacteriological  grounds,  in  using  the  same  animal 
sugar  in  substitute  feeding  that  is  found  in  the  infant's  natural  food,  in- 
stead of  introducing  a  vegetable  sugar,  which  in  milk  is  a  foreign  element. 
The  dangers  from  lactic  acid  are,  at  any  rate,  much  exaggerated  by  writers 
on  this  subject. 

Caseinogen. — Caseinogen  or  calcium-casein  is  the  term  applied  to  the 
chief  proteid  of  milk.  According  to  Van  Slyke  and  Hart,  the  casein  is  not 
in  true  solution  in  milk,  but  exists  as  very  minute,  solid,  gelatinous  parti- 
cles in  suspension.  In  the  presence  of  very  dilute  acid,  the  acid  first  unites 
with  the  calcium  of  the  calcium-casein,  setting  free  the  base-free  casein, 
which  then  combines  with  more  acid  and  forms  a  salt  of  the  acid.  This 
salt  is  the  familiar  coagulum  or  curd  of  milk  and  may  be  either  casein 
lactate  or  casein  hydrochloride. 

In  the  presence  of  alkalies,  such  as  the  hydroxides  of  sodium,  potas- 
sium, ammonium  and  calcium,  the  free-base  casein,  or  its  acid  salts,  form 
compounds  which  are  easily  soluble  in  water  and  which  do  not  react  with 
the  rennin  ferment  to  form  curds.  This  explains  the  beneficial  action 
observed  clinically  when  strongly  alkaline  milks  are  given  in  infant  feed- 
ing. The  alkaline  compounds  of  casein  which  are  formed,  forming  no 
curds,  pass  more  quickly  into  the  duodenum  and  are  acted  upon  by  the 
pancreatic  digestion,  the  gastric  digestion  being  completely  or  partially  in- 
hibited, depending  upon  the  extent  to  which  the  milk-casein  is  converted 
into  alkaline  compounds  of  casein. 

The  action  of  the  rennin  ferment,  one  of  the  constituents  of  gastric 
secretum,  on  calcium-casein  is  first  to  form  what  Van  Slyke  and  Hart 
call  calcium-paracasein,  which,  in  the  absence  of  soluble  calcium  salts, 
remains  uncoagulated,  but  in  their  presence,  it  appears  as  a  coagulum  or 
curd.  The  coagulated  calcium-paracasein  behaves  in  the  presence  of 
the  hydrochloric  acid  of  the  gastric  juice  much  like  calcium-casein,  that 
is,  the  first  portion  of  the  acid  removes  the  calcium  and  leaves  free- 
base  paracasein,  and  the  further  action  of  the  acid  forms  free  para- 
casein salts  of  the  acid  with  which  it  comes  in  contact.  There  is, 
therefore,  very  little  chemical  difference  between  calcium- casein  and 
calcium-paracasein . 

The  formation  of  curds  both  by  rennin  and  by  the  acids  of  the  gastric 
juice  appears  to  be  an  effort  of  nature  to  throw  a  part  of  the  burden  of 
proteid  digestion  upon  the  stomach,  by  delaying  the  passage  of  food  into 
the  duodenum.  Chapin  has  sho\vn  that  this  function  of  digestion  plays  an 
important  part  in  the  development  of  the  stomach  itself,  and  is  therefore 
to  be  encouraged  up  to  the  limit  of  the  infant's  ability  to  digest  the  casein. 
On  the  other  hand,  these  interesting  observations  of  Van  Slyke  and  Hart 
emphasize  the  danger  of  overtaxing  the  gastric  chgestion  by  giving  too  large 
proportions  of  casein.  We  also  see  the  scientific  explanation  of  the  benefit 
derived  by  reducing  the  amount  of  casein  in  cases  of  gastric  indigestion. 


172  l-EDIATinCS. 

ami  uf  making  the  milk  so  alkaline  that  it  will  pass  quickly  into  the  duo- 
denum and  thus  relieve  the  stomach  of  the  function  which  hi  abnormal 
conditions  it  is  often  incapable  of  performing. 

In  the  management  of  the  food  in  all  cases  of  feeding,  then,  the  effort 
of  the  physician  must  be  to  estal^lish  an  equilibrium  between  the  quality 
of  the  mifk  and  the  infant's  capacity  to  digest  it.  To  do  this  one  should 
appreciate  certain  conditions  affecting  rennet  coagulation.  Tliese  have 
been  summarized  by  Van  Slyke  as  follows : 

(1)  The  presence  of  soluble  lime  salts  appears  to  be  necessary  for  rennet  coagula- 
tion of  milk. 

(2)  The  reaction  must  be  neutral  to  litmus,  or  acid,  but  not  alkaline.  Acids, 
whether  organic  or  inorganic,  though  they  differ  from  one  another  in  respect  to  the 
intensity  of  the  influence  which  they  exert  on  rennet  action,  show  very  marked  eflfect 
upon  the  coagulation  of  calcium-casein  by  rennet.  This  effect  of  acids  upon  rennet 
action  is  commonly  explained  by  saying  that  the  addition  of  acid  dissolves  the  insol- 
uble calcium  phosphate  of  milk  and  thus  increases  the  amount  of  soluble  calcium 
salts.  The  claim  is  also  made  by  some  that  the  acid  in  itself  has  some  direct  influence 
upon  the  action  of  rennet. 

(3)  Dilution  of  milk  by  Avater  delays  rennet  coagulation  of  milk,  because  the 
proportion  of  soluble  calcium  salts  is  decreased.  Addition  of  calcium  chlorid  or  of  a 
free  acid  to  milk  diluted  by  water  not  only  hastens  the  time  of  coagulation  but  increases 
the  amount  of  calcium-casein  coagulated, 

(4)  Different  chemical  compounds  affect  the  coagulation  of  milk  by  rennet  in 
different  ways.  Many  acid  salts  act  like  free  acids  in  hastening  rennet  action.  Alka- 
lies and  alkaline  salts  retard  it.  The  following  substances  also  are  among  those  that 
retard  rennet  action  :  Sodium  chlorid,  disodium  hydrogen  phosphate,  sodium  acetate, 
boric  acid,  chloroform,  formalin,  etc. 

"When  lime  water  is  added  to  cow's  milk  until  it  is  neutral  or  faintly  alkaline  to 
phenolphthalein,  a  basic  calcium-casein  is  formed  which  is  not  acted  upon  by  rennet, 
and  will  not  form  a  curd  even  in  the  presence  of  soluble  lime  salts.  Other  alkalies 
probably  produce  similar  basic  compounds  with  casein. 

(5)  Addition  of  foreign  inert  matter,  like  starch  or  sawdust,  hastens  rennet  action. 

(6)  Temperature  affects  the  rapidity  of  coagulation  of  milk  by  rennet.  For  com- 
plete action,  the  time  decreases  as  the  temperature  increases.  In  a  given  time  rennet 
coagulates  milk  most  completely  at  106°  to  108°  F.,  and  less  completely  at  tempera- 
tures above  and  below  this. 

(7)  The  temperature  of  coagulation  affects  the  character  of  the  coagulum.  At  60° 
F.  the  curd  is  flocculent,  spongy  and  soft ;  at  77°  F.  to  113°  F.  it  is  more  or  less  firm 
and  solid  ;  at  122°  F.  and  above,  it  is  very  soft,  loose  and  more  or  less  gelatinous. 

(8)  Rennet  heated  for  some  time  to  over  140°  F.  becomes  permanently  weaker  or 
inactive  and  is  somewhat  affected  at  about  120°  F.  Weak  solutions  are  more  easily 
affected  than  strong  solutions  by  increase  of  temperature. 

(9)  Increase  in  amount  of  rennet  in  proportion  to  milk  hastens  rapidity  oi  coagu- 
lation ;  likewise,  increase  in  strength  of  rennet. 

(10)  Milk  freshly  drawn  curdles  more  completely  than  when  allowed  to  cool,  due 
to  temperature  and  perhaps  to  the  presence  of  carbon  dioxid. 

(11)  Milk  heated  above  1-50°  F.  for  a  considerable  length  of  time  coagulates  less 
rapidly  than  normal  milk.  The  coagulum  of  heated  milk  is  highly  flocculent,  unless 
one  adds  soluble  calcium  salts  or  some  acid.     Boiled  milk  does  not  coagulate  normallv. 


FEEDING.  173 

if  at  all,  by  rennet.      Heating  milk  decreases  the  amount  of  soluble  calcium  salts  in  the 
milk,  and  also  removes  any  carbon  dioxid  that  may  be  present. 

(12)  Milk  from  different  cows,  or  from  the  same  cow  at  different  times,  behaves 
very  differently  toward  rennet. 

(13)  In  the  absence  of  acid,  calcium-paracasein  fails  to  be  digested  by  pepsin, 
while  paracasein,  paracasein  lactate,  casein,  casein  lactate  and  casein  hydrochlorid  are 
partially  digested.  Casein  and  paracasein,  in  the  absence  of  acid,  are  digested  more 
than  their  lactates.  In  the  presence  of  0.4  per  cent,  of  hydrochloric  acid,  paracasein 
lactate  is  digested  by  pepsin  more  than  is  paracasein.  Paracasein  and  casein  and  their 
lactates  digest  more  readily  and  completely  in  the  presence  of  free  hydrochloric  acid 
than  in  its  absence.  Casein  lactate  and  casein  hydrochlorid  do  not  differ  in  the 
rapidity  and  extent  to  which  they  are  converted  into  soluble  compounds  by  pepsin. 
The  rapidity  of  digestion  is  dependent  in  part  upon  the  fineness  of  material  digested. 


Van  Slyke  has  also  called  attention  to  the  influence  of  chemical  re- 
agents, of  enzymes  and  of  various  organisms  by  whicli  calcium-casein  may 
be  changed  into  a  great  number  cf  other  substances,  such  as  paranuclein, 
albumoses,  peptones,  amides  or  crystallizable  bodies,  and  ammonia. 
These  products  are  not  normally  found  in  perfectly  fresh  cow's  milk,  but 
may  occur  after  milk  has  stood  for  some  time  under  improper  conchtions. 
As  these  products  may  be  distinctly  deleterious  to  an  infant,  we  see  the  great 
importance  of  scrupulous  care  in  the  collection  and  handling  of  milk. 
Pasteurization  or  sterilization  of  an  impure  milk  will  not  destroy  abnormal 
and  sometimes  dangerous  compounds. 

The  amount  of  calcium-casein  in  cow's  milk  averages  about  2.66  per 
cent. ;  whereas  the  amount  of  albumin  and  nitrogenous  extractives 
averages  0.84  per  cent.  As  the  period  of  lactation  in  the  cow  advances 
there  is  a  tendency  for  them  both  to  increase.  Van  Slyke  found  that  the 
relation  between  the  calcium-casein  and  albumin  varied  greatly  in  their 
relation  to  each  other,  the  average  being  about  3.6  parts  of  casein  to  1  of 
albumin. 

WHEY-PROTEms. — The  lactalbumin,  including  the  small  traces  of  lacto- 
globulin,  and  of  the  other  nitrogenous  extractives,  form  about  twenty-five 
per  cent,  of  the  total  proteids  of  milk  or  0.84  per  cent.  In  human  milk,  it  is 
of  much  greater  importance,  constituting  one-half  to  two-thirds  of  the  total 
proteids.  It  is  characterized  by  its  property  of  coagulating  at  72°  to  84° 
C,  the  degree  depending  upon  the  amount  of  salt  in  solution.  It  is  not 
coagulable  by  dilute  acids  or  rennin.  It  is  very  similar  chemically  to 
serum  albumin.  When  heated  at  the  above  temperature  it  is  not  entirely 
coagulated,  but  is  so  changed  that  it  is  readily  precipitated  by  magnesium 
sulphate.  Much  stress  has  recently  been  laid  upon  the  difference  in  the 
relative  proportions  of  the  two  proteids  in  its  application  to  infant  feeding. 
According  to  some  analyses,  however,  caseinogen  is  in  excess  of  the  whey- 
proteids  even  in  human  milk,  but  nearly  all  are  agreed  as  to  the  relatively 
greater  proportion  of  soluble  proteids  in  human  milk  as  compared  with 
cow's  milk.     Our  analyses  of  milk  have  been  made  in  reference  to  the 


174  PEDIATRICS. 

relative  proportions  of  caseinogeii  and  wliey-proteids,  as  the  nitrogenous 
extractives  being  soluble  nitrogenous  compounds  are  necessarily  associated 
with  the  lactalbumin  in  all  materials  derived  from  milk  which  are  used 
in  infant  feeding.  The  great  majority  of  analyses  of  breast-milk  do  not 
attempt  to  give  anything  more  than  the  total  proteids. 

It  is  also  probable  that  there  are  qualitative  differences  in  the  caseins 
of  cow's  milk  and  human  milk,  but  whether  these  differences  in  the  com- 
position of  the  casein  molecules  wholly  account  for  the  differences  in  the 
character  of  the  coagula  of  the  two  milks,  or  whether  the  differences  are 
in  part  due  to  the  unequal  relationship  of  the  casein  and  salts  in  the 
two  kinds  of  milk,  is  not  determined.  It  has  been  shown  that  when 
cow's  milk  is  so  modified  by  the  addition  of  whey  and  cream,  as. to 
correspond  in  its  proportions  of  caseinogen  and  whey-proteids  to  that 
of  human  milk,  the  coagulum  obtained  by  the  addition  of  rennin  or  acids 
is  not  coarse  and  tough,  butfme  and  flocculent,  resembling  that  of  mother's 
milk. 

Other  Nitrogenous  Substances  in  Milk. — Various  laboratory  products 
may  be  produced  from  the  proteids  of  milk,  such  as  albumose,  peptone, 
and  lactoprotein,  but  it  has  not  been  proved  that  they  occur  in  nature.  A 
part  of  the  nitrogen  of  milk  exists  as  extractives. 

Mineral  Matter. — The  mineral  matter  of  cow's  milk  has  been  ana- 
lyzed with  comparative  care  and  success.  The  total  salts  obtained  by  the 
analyses  of  Konig  was  7.1  parts  in  1000  parts,  or  0.71  per  cent.  According 
to  Soldner,  the  potassium,  sodium,  and  chlorine  are  found  in  the  same 
quantities  in  whole  milk  as  in  milk-serum.  Of  the  total  phosphoric  acid, 
36  to  56  per  cent.,  and  of  the  lime,  53  to  72  per  cent.,  is  not  in  solution. 
A  part  of  the  lime  is  combined  with  the  caseinogen  ;  the  remainder  is  found 
united  with  the  phosphoric  acid  as  a  mixture  of  dicalcium  and  tricalcium 
phosphate,  which  is  kept  dissolved  or  suspended  by  the  caseinogen.  The 
bases  are  in  excess  of  the  mineral  acids  in  the  milk-serum,  and  the  excess 
~of  the  former  is  combined  with  organic  acids.  At  present  the  percentage 
of  the  mineral  matter  in  cow's  milk  does  not  enter  into  the  clinical  modi- 
fication of  milk,  but  a  more  extended  knowledge  of  the  subject  may  in  the 
future  be  found  to  be  of  importance. 

The  differences  between  the  constituents  of  the  mineral  matter  of 
human  milk  and  of  that  of  cow's  milk  are  as  follows :  in  cow's  milk  there 
are  more  lime,  magnesia,  potassium,  much  more  phosphoric  acid,  and 
less  chlorine  and  sulphur. 

"Water. — There  is  about  one  per  cent,  less  of  water  in  cow's  milk  than 
in  human  milk.  Chemical  analyses  invariably  show  so  large  an  amount 
of  water  in  human  milk  that  it  is  evident  that  the  infant  is  intended  to  take, 
and  can  best  assimilate,  a  very  dilute  food.  We  must  bear  this  fact  in 
mind  in  preparing  a  substitute  food,  as  the  precaution  of  supplying  a 
thoroughly  diluted  food  is  of  extreme  importance  in  managing  the  infant's 
feeding  both  in  health  and  in  disease. 


FEEDING.  175 

Gases. — Oxygen,  nitrogen,  and  carbon  dioxide  are  present  in  fresli 
milk  and  are  probably  due  to  absorption  from  air.  Boiling  and  steriliza- 
tion of  milk  in  open  bottles  causes  the  carbon  dioxide  to  volatilize,  and  to 
this  fact,  rather  than  to  chemical  changes,  is  due  the  unpleasant  taste  of  milk 
heated  in  open  vessels.  The  pleasant  taste  can  be  restored  if  carbon 
dioxide  is  artificiahy  incorporated  with  the  milk  as  by  the  addition  of 
aerated  waters.  A  large  proportion  of  the  natural  gas  of  milk  disappears 
when  milk  is  centrifugalized. 

Action  of  Heat  on  Milk. — When  milk  is  heated  to  70°  C,  a  certain 
amount  of  lactalbumin  and  lactoglobulin  is  coagulated,  but  the  greater  part 
of  the  lactalbumin  is  converted  into  a  form  which  is  precipitated  by  acids, 
by  magnesium  sulphate,  and  by  other  precipitants  of  casein  Avhich  do  not 
act  upon  the  lactalbumin  in  its  natural  state.  At  80°  C,  certain  organ- 
ized principles  undergo  a  change,  the  nature  of  which  is  not  known,  but 
the  evidence  of  which  is  found  in  certain  chemical  reactions.  At  100°  C, 
calcium  citrate  is  deposited,  some  oxidation  of  the  sugar  takes  place,  and 
a  deposition  of  albumin  and  certain  salts  on  the  fat  globules  occurs,  caus- 
ing the  latter  to  rise  and  coalesce.  At  a  temperature  exceeding  60°  C,  a 
skin  is  formed  on  the  surface  of  the  milk,  consisting  probably  of  an  oxid- 
ized product  of  casein  together  with  calcium  salts  and  some  fat.  It  is 
practically  an  evaporated  milk.  AVhen  heated  above  70°  C,  the  taste  and 
smell  of  milk  are  altered. 

Fresh  milk  does  not  coagulate  on  boiling,  but  when  lactic  acid  fermen- 
tation has  proceeded  sufficiently  far  coagulation  occurs  on  the  application 
of  heat,  a  phenomenon  often  noticed  in  summer  when  the  conditions  are 
especially  favorable  to  lactic  acid  fermentation.  This  is  probably  due  to 
the  acid  developed  displacing  the  casein  from  its  combination  with  an 
alkali,  the  free  acid  manifesting  its  properties.  Lactic  acid  fermentation  is 
checked  by  the  action  of  heat  and  by  the  addition  of  lime-water  or  bicar- 
bonate of  soda. 

Heat  does  not  destroy  the  ptomaines  or  toxines  which  have  been  formed 
by  the  growth  of  micro-organisms  in  milk ;  it  only  checks  for  a  varialDle 
length  of  time  the  growth  of  bacteria  with  its  deleterious  products  ;  hence 
the  pasteurization  or  sterilization  of  an  already  contaminated  and  infected 
milk  can  never  make  up  for  a  lack  of  a  clean,  uncontaminated  milk 
supply.  According  to  H.  Bitter  all  pathogenic  germs  are  killed  with  cer- 
tainty at  a  temperature  of  68°  C.  (154.4°  F.)  continued  for  one-half  hour, 
and  the  milk  is  thereby  not  altered  in  taste  or  appearance.  Ordinarily 
twenty  minutes  exposure  is  sufficient.  Most  bacteria  are  killed  at  from 
60°  to  64°  C.  (140°  to  147°  F.),  but  Theobold  Smith  has  demonstrated 
that  the  tubercule  bacillus  may  survive  an  exposure  of  an  hour  at  65°  C. 
(149°  F.),  so  that  these  lower  temperatures  are  not  to  be  relied  upon. 
The  spores  of  the  bacteria,  however,  and  some  of  the  casein  ferments  are 
not  destroyed  by  a  single  pasteurization.  Sterihzation  of  milk  under  press- 
ure for  two  hours  at  120°  C.  (248  F°.)  is  sufficient  to  destroy  spores.     At 


17(3  PEDIATRICS. 

such  temperatures,  however,  the  sugar  is  converted  into  caramel,  many  of 
tlie  natural  ferments  are  destroyed,  the  casein  is  partially  precipitated,  and 
in  the  opinion  of  many  the  nutritive  value  of  the  milk  is  seriously  interfered 
with.  A  temperature  of  68.3°  C.  (155°  F.)  is  the  temperature  which  may 
most  profitably  be  relied  upon  for  the  pasteurization  of  milk.  It  is  suffi- 
ciently high  to  kill  most  of  the  organisms  which  are  found  in  milk,  and  at 
the  same  time  does  not  produce  any  chemical  changes  that  may  be 
detected. 

It  is  not  known  with  certainty,  despite  the  many  opinions  expressed 
on  the  point,  as  to  how  far  the  heating  of  the  milk  at  low  temperatures 
affects  its  digestive  qualities.  A  milk  heated  at  high  temperatures  is  curdled 
less  readily  by  rennin  than  is  unheated  fresh  milk,  but  there  is  reason  to 
believe  that  this  is  due  to  the  deposition  of  the  calcium  salts  rather  than  to 
any  change  in  the  casein.  On  the  other  hand,  it  has  been  claimed  that 
sterilized  milk  is  easier  of  digestion  in  the  stomach  and  does  not  produce 
so  firm  a  clot,  the  explanation  probalDly  being  that  it  passes  more  quickly 
into  the  duodenum. 

Effect  of  Cold  on  Milk. — Cold  is  a  most  important  factor  in  preventing 
the  growth  of  bacteria  in  milk.  If  the  temperature  is  sufficiently  low, 
about  15.5°  C.  (31°  F.)  the  milk  will  freeze.  The  frozen  portion  does  not 
show  the  same  composition  as  the  milk  itself,  but  contains  a  larger  pro- 
portion of  water. 

Separated  Milk. — Separated  milk  is  the  term  applied  to  a  milk  from 
which  the  fat  lias  been  wholly  or  partially  removed,  either  by  the  centri- 
fuge or  by  gravity.  Obviously,  therefore,  it  has  no  constant  composition. 
Milk  from  which  the  fat  lias  been  removed  by  the  ordinary  process  of 
skimming  contains  from  0.4  to  1.2  per  cent,  of  fat.  The  proportions  of  the 
other  ingredients  depend  upon  the  proportion  of  the  fat  removed.  They 
are  increased  by  the  removal  of  the  fat.  If  the  centrifugal  separator  is 
worked  to  its  maximum  capacity,  practically  all  the  fat  is  separated  out  as 
^ream,  leaving  a  slimy  residue,  and  the  milk-plasma,  and  to  the  latter  the 
term  "  fat-free  milk  "  is  now  given.  Many  analyses  of  this  milk  at  the 
Walker-Gordon  Laboratories  have  shown  the  fat  to  be  approximately  only 
0.05  per  cent.  About  the  same  percentage  of  fat  (0.05)  is  to  be  found  in 
the  lowest  eight  ounces  of  a  jar  of  milk  which  has  been  setting  eight  or 
twelve  hours,  so  that  a  milk  practically  fat-free  can  be  obtained  by  both 
gravity  and  by  centrifugal  methods. 

The  slimy  residue  mentioned  above  consists  of  casein,  inorganic 
impurities  such  as  dirt,  vegetable  matter  from  the  fodder,  substances 
from  the  cow,  such  as  hair,  pavement  cells  from  the  udder,  empty  gland 
cells,  micro-organisms,  and  sometimes  pus  and  blood.  While  centri- 
fugal cream  is  much  cleaner  than  the  milk  from  which  it  is  derived,  the 
process  of  separation  does  not  materially  diminish  the  number  of  micro- 
organisms. 

Creams. — Cream  is  the  term  applied  to  the  separated  part  of  the  milk 


FEEDING.  177 

which  is  especially  rich  in  fat.  It  is  of  the  same  qualitative  composition  as 
milk,  but  with  different  proportions  of  the  ingredients.  The  richer  the 
cream  is  in  fat,  the  lower  is  its  percentage  of  proteids  and  sugar.  See 
page  168. 

Fig.  47,  page  206,  a  photomicrograph  of  a  thin  layer  of  nn'lk,  shows  the 
minute  globules  of  fat  permeating  the  transparent  medium.  This  fat  is 
simply  held  in  suspension,  which  enables  us  to  separate  it  easily  by  me- 
chanical means.  It  is,  in  juit,  in  the  condition  which  marks  the  milk  as  an 
emulsion. 

Attenuants. — So  much  has  been  said  about,  and  so  many  physicians 
are  in  favor  of,  diluting  cow's  milk  with  such  attenuants  as  barley- 
water  and  other  cereal  waters,  that  a  clear  understanding  should  be  had 
as  to  the  true  position  which  sucli  attenuation  sliould  hold  in  infant 
feeding. 

One  of  the  objects  which  physicians  expect  to  attain  with  cereal  at- 
tenuants is  that  in  some  mechanical  way  the  attenuant  breaks  up  the 
coagulated  proteids  into  liner  particles  than  when  the  milk  is  simply  diluted 
with  water  or  lime-water  or  solutions  of  sugar.  Barley-water  seems  to  be 
the  best  attenuant  for  this  purpose,  and  in  comparing  the  coagulum 
obtained  by  the  dilution  made  with  this  cereal  with  that  made  with 
water,  lime-water,  or  sugar- water,  it  is  found  to  be  somewhat  finer  in 
the  former  than  in  the  latter.  The  barley-water  should  be  made  as 
directed  on  page  184.  A  decoction  of  barley-water  made  in  this  way 
contains  rather  less  than  one  per  cent,  of  starch.  This  proportion  of 
starch  does  not  add  materially  to  the  nutritive  value  of  the  mixture  in 
young  infants,  and  must  merely  be  looked  upon  as  a  foreign  element 
which  is  never  found  in  human  milk.  It  has  also  been  recommended 
by  certain  physicians  that  this  starch  in  the  cereal  attenuant  be  dextrin- 
ized,  in  order  to  increase  its  food  value.  Such  treatment  lessens  its 
mechanical  effect  upon  the  coagulum  of  milk.  Human  milk  never  con- 
tains starch  ;  the  amylolytic  function  of  tlie  infant  is  not  fully  developed 
in  the  early  months  of  life,  and  should  not  be  overtaxed  in  the  process  of 
its  development. 

The  newer  and,  in  our  experience,  more  successful  methods  of  dealing 
with  the  coagulum  are  not  only  to  dilute  sufficiently  with  water,  but  so  to 
treat  the  total  proteids  in  the  mixture  that  the  relative  proportion  of  whey- 
proteids  and  caseinogen  shall  approach  as  nearly  as  possible  to  that  which 
is  supposed  to  exist  in  the  proteids  of  human  milk.  In  this  way  the  pro- 
portion of  caseinogen  being  very  much  lessened,  the  resulting  coagulum 
of  casein  will  be  much  smaller,  and  practically  so  fine  that  any  mechanical 
attenuant  becomes  unnecessary. 

Cow's  Milk  as  compared  with  Woman's  Milk. — We  may  in  conclud- 
ing the  subject  of  the  chemistry  of  cow's  milk  summarize  the  principal 
points  of  difference  between  cow's  milk  and  human  milk  in  the  follow- 
ing table  : 

12 


178  I'EDIATIUCS. 

TABLE  42. 

Woman's  milk  directly  from  the 

breast.  Co\v"s  milk,  freshly  milked. 

Reaction Amphoteric.       (More  alkaline  Amphoteric.      (More   acid 

than  acid. )  than  alkaline. ) 

Water 87  to  88  per  cent.  86  to  87  per  cent. 

Mineral  matter 0.20  per  cent.  0.70  per  cent. 

Total  solids 13  to  12  per  cent.  14  to  13  per  cent. 

Fats 4.00  per  cent,  (relatively  poor  4.00  per ct.  (relatively  rich 

in  volatile  glycerldes. )  in  volatile  glycerides.  > 

Milk-sugar 7.00  per  cent.  4.75  per  cent. 

Proteids l.oO  per  cent.  3.50  per  cent. 

Caseinogen J  to  ^  of  the  total  proteids  2.66  per  cent. 

Whey-proteids t  to  J  "     "      "  "  0.84  per  cent. 

Coagulable proteids Small  proportionally.  Large  proportionally. 

Coagulation  of  proteids  by 

acids  and  salts With  greater  difficulty.     Curds  With  less  difficulty.  Curds 

small  and  fiocculent.       •  large  and  tenacious. 

Coagulation  of  proteids  by 

rennet Does  not  coagulate  readily.  Coagulates  readily. 

Action  of  gastric  juice...     Proteids  precipitated  but  easily  Proteids  precipitated  but 

dissolved  in  excess  of  the  gas-         dissolved  less  readily. 

trie  juice. 

The  Production  of  Sterile  Milk. — The  production  of  milk  tliat  is  free 
from  dirt  and  bacteria  is  tlie  first  consideration  in  any  ideal  method  of 
infant  feeding.  The  standard  for  such  purity  is  to  be  found  in  human  breast- 
milk.  This  practically  is  a  sterile  fluid,  and  its  freshness  and  freedom  from 
both  bacteria  and  their  toxines  are  two  of  the  principal  reasons  for  the 
undeniable  superiority  of  breast  over  bottle  feeding.  The  sterilization  of  a 
contaminated  milk,  while  lessening  the  danger  which  arises  from  continued 
growth  of  organisms,  does  not  destroy  the  poisonous  effects  of  the  toxines 
already  formed.  Sterilization  and  pasteurization,  therefore,  do  not  do 
away  with  the  necessity  of  using  the  strictest  precautions  in  the  collection 
and  handling  of  the  milk.  Milk  is  one  of  the  most  favorable  culture  media 
'Tor  bacteria.  The  conditions  under  which  it  is  obtained  make  it  peculiarly 
difficult  to  prevent  it  from  becoming  infected.  The  use  of  any  preventa- 
tive is  absolutely  unjustifiable  in  milk  which  is  to  be  used  for  the  feeding 
of  infants.  The  mortality  and  disease  engendered  by  contaminated  and 
adulterated  milk,  especially  in  warm  weather,  is  enormous.  The  most 
careful  modification  of  an  impure  supply  will,  therefore,  give  unsatisfactory 
results.  The  greatest  advances  in  the  subject  of  substitute  feeding  in  this 
country  are  to  be  found  in  the  progress  which  has  been  made  in  certain 
well  regulated  farms  by  applying  to  every  step  in  the  collection  and  hand- 
ling of  milk  the  principles  of  cleanliness. 

In  the  milk  commonly  used  in  cities  the  number  of  bacteria  to  the  cubic 
centimetre  amounts  to  half  a  million  or  more.  Ten  thousand  bacteria  per 
cubic  centimetre  is  considered  the  maximum  for  good  milk.  In  the  year 
1899  a  daily  examination  of  the  milk  produced  by  one  of  the  farms  con- 


FEEDING.  179 

nected  with  the  milk-laboratory  in  Philadelphia  was  made  at  the  Pepper 
Laboratory.  The  average  for  334  days  was  1530  bacteria  per  cubic  centi- 
metre ;  and  this  number  fell  in  the  autumn  and  winter  to  1150  to  1195 
per  cubic  centimetre.  These  figures  show  how,  witli  especial  care  at  the 
farms,  milk  can  be  radically  changed  in  regard  to  the  number  of  bacteria 
it  contains. 

The  bacteria  which  are  usually  present  may  or  may  not  be  patliogenic, 
but  the  bacterial  count  is  the  only  reliable  guide  as  to  the  care  which  is 
taken  of  the  milk.  A  supply  so  carelessly  obtained  as  to  permit  of  any  such 
development  of  bacteria  as  has  been  mentioned  is  dangerous,  if  not  from 
the  variety  of  the  infecting  organisms,  at  least  as  an  indication  that  such  a 
milk  may  at  any  time  become  contaminated  by  some  bacteria  that  may 
prove  a  direct  cause  of  disease.  Practical  experiment  shows,  moreover, 
that  the  products  of  the  growth  of  bacteria,  which  are  classed  as  non- 
pathogenic, are  usually  harmful  to  the  infant,  by  causing  intestinal  in- 
digestion and  paving  the  way  for  direct  infection  by  specific  pathogenic 
organisms. 

The  methods  employed  in  the  production  of  a  pure,  practically  sterile 
milk  need  not  be  described  here  in  great  detail.  They  are,  as  has  been 
stated,  dependent  upon  strict  cleanliness.  The  cow  barns  should  be 
arranged  with  facilities  for  the  immediate  and  thorough  removal  of  manure, 
for  the  disinfection  of  the  stalls  and  the  exclusion  of  flies.  The  feed  should 
be  in  a  separate  building,  at  a  safe  distance  from  the  barn.  The  cows  should 
be  kept  well  groomed,  and  carefully  wiped  with  damp  cloths  before  each 
milking.  The  milk  pails  should  be  sterilized  and  the  milkers  obliged  to 
wear  clean  caps  and  canvas  suits,  and  to  scrub  their  hands  before  each 
milking.  The  first  of  the  milk  from  each  teat  should  be  discarded,  as  the 
bacteria  penetrate  into  the  lacteal  ducts.  After  the  milk  has  been  drawn 
it  should  be  cooled  and  bottled  at  once.  To  do  this  to  the  best  advantage 
the  most  hygienic  dairies  are  provided  with  apparatus  by  which  the  milk 
can  be  cooled,  aerated,  strained  and  bottled  with  only  a  few  minutes 
exposure  to  the  air.  The  cream  is  separated  by  means  of  a  DeLaval  cen- 
trifugal separator  immediately  after  cooling  and  aeration,  and  thus  has 
a  distinct  advantage  over  creams  that  have  been  obtained  by  gravity, 
in  that  it  is  much  freer  from  dirt,  most  of  which  is  separated  from  the 
milk  in  the  separator,  and  from  germs,  owing  to  its  shorter  exposure. 
The  storing  of  milk,  keeping  it  surrounded  with  ice  from  the  time  it  is 
bottled  until  use  in  the  modifications  is  the  final  step  in  the  hygiene  of  the 
dairy. 

All  these  precautions  necessarily  involve  considerable  expense  in  the 
running  of  a  first-class  dairy,  especially  as  there  are  many  other  details  to 
be  observed,  such  as  the  periodical  inspection  of  the  herds  by  a  veterina- 
rian, the  inspection  of  the  milkers  by  a  physician,  and  the  testing  of  the 
cows  for  tuberculosis  by  tuberculin  injections,  and  the  bacteriological  and 
chemical  examination  of  the  milk  to  maintain  a  standard  quality.    For  the 


ISO  PEDIATRICS. 

protection  and  safety  of  such  a  milk  supply  the  public  must  expect  to  pay 
higher  prices  than  it  has  been  accustomed  to,  and  it  rests  largely  with  the 
physicians  to  impress  upon  it  the  desirability  and  even  the  necessity  of 
procuring  the  best  and  cleanest  milk  possible  for  infants,  who  must  be 
reared  on  other  food  than  that  which  is  supplied  by  the  breast. 

■  The  selection  of  the  herd  and  the  production  of  a  practically  sterile 
milk  of  constant  composition  therefore  constitute  the  first  essential  points  in 
the  modern  metliod  of  substitute  feeding.  The  second  and  no  loss  im- 
portant feature,  is  the  modification  of  the  milk  in  its  percentage  com- 
positions so  as  to  make  it  resemble  more  closely  that  of  human  milk  ;  and, 
by  such  changes  as  may  be  indicated  by  the  age,  development  and  the  state 
of  digestion  of  the  infant,  to  adapt  it  to  the  rec|uirements  of  the  especial 
case. 

The  Theory  of  Percentage  Modification  of  Milk. — The  idea  of 
modification  of  milk  according  to  definite  percentages  of  fats,  sugar  and 
proteids,  in  order  to  adapt  it  to  the  varying  requirements  of  infants  is  the 
basis  of  modern  scientific  methods  of  substitute  feeding. 

Substitute  feeding  is  the  administration  of  some  other  food  than  breast- 
milk  during  the  first  year  of  life.  We  liave  emphasized  the  great  superiority 
of  breast  feeding  over  all  other  methods  when  the  quality  and  quantity  of 
the  breast-milk  is  adapted  to  the  needs  of  the  infant.  Substitute  feeding  is 
resorted  to  only  as  a  matter  of  necessity,  but  admitting  the  necessity  to 
exist,  we  can  by  intelligent  modification  and  adaptation  of  cow's  milk 
provide  a  food  which  in  the  great  majority  of  cases  will  prove  a  safe,  prac- 
ticable and  successful  substitute  for  breast-milk.  It  is  necessary,  however, 
that  we  should  clearly  understand  the  principles  of  milk  modification  and 
percentage  feeding.  Having  grasped  these  principles  we  may  modify  milk 
at  home,  or  use  that  which  is  prepared  at  the  milk-laboratories,  which, 
because  of  the  purity  and  reliability  of  the  milk  supply,  the  accuracy  of  the 
modifications  and  the  convenience  as  a  labor-saving  device  to  both  mother 
^-and  physician,  furnish  by  all  means  the  most  rational  and  successful 
method  of  feeding  of  which  we  know. 

Modified  Milk. — A  modified  milk  is  a  milk  to  which  anything  has 
been  added,  or  from  which  anything  has  been  taken,  by  which  its  per- 
centage composition  is  altered.  Thus  the  addition  of  water  alone,  or  of 
sugar,  or  of  cream,  gives  a  different  percentage  combination.  Unless  an 
infant  can  digest  whole  cow's  milk,  percentage  modification  becomes  an 
inevitable  necessity  in  every  case  of  substitute  feeding.  In  practice  it  is 
simply  a  question  of  whether  the  physician  shall  prescribe  accurately  a 
modification,  the  percentage  of  which  is  approximately  known,  or  shall  use 
empirically  mixtures  of  unknown  percentages,  subject  to  wide  variations 
without  his  knowledge.  The  modern,  scientific  and  approximately  ac- 
curate system  of  substitute  feeding  has  all  the  advantages  of  the  older 
methods  and  in  a  large  measure  is  free  from  their  objections.  It  is 
desirable  for  physicians  to  get  into  the  habit  of  thinking  and  writing  in 


FEEDING.  181 

perceiitayi's,  as  it  leads  to  more  exactness  in  tlie  feeding  and  nialces  tlie 
experience  gained  in  one  case  of  value  in  the  management  of  another. 

The  infant  at  the  breast  receives  for  its  nutriment  a  fluid  which  is 
fresh,  sterile,  amphoteric,  wliich  has  a  temperature  of  36.7°-37.8°  C.  (98°- 
100°  F.),  furni-shed  in  an  amount  proportionate  to  the  age  and  size  of  the 
consumer.  It  is  this  fluid  which  we  have  to  copy  in  every  possible  detail 
when  we  undertake  to  prepare  a  substitute  food.  We  should  also  consider 
as  foreign  matter,  to  be  carefully  avoided  in  the  early  months  of  life, 
any  element  which  we  know  is  not  to  be  found  in  the  milk  wo,  are 
copying. 

In  quite  a  number  of  cases  rather  gross  changes  in  the  percentages  of 
the  different  elements  of  the  milk  may  be  sufficient  for  the  range  of  the 
individual  digestion  and  for  the  nutrition  of  the  especial  case,  but  it  has 
been  our  experience  with  a  very  large  number  of  infants  whose  vitality 
was  low  and  whose  malnutrition  was  extreme,  to  find  that  the  lives  of 
these  infants  could  only  be  preserved  by  gradual  and  slight  changes  in  the 
percentages  and  combinations  of  the  milk-elements.  We  therefore  cannot 
be  too  particular  in  assuring  ourselves  that  we  are  using  a  milk  modifica- 
tion which  is  as  precise  as  any  knowledge  up  to  the  present  time  has 
made  it  possible  to  be.  Even  slight  changes,  therefore,  in  the  percentages 
of  the  three  important  elements  of  milk  of  which  we  have  most  accu- 
rate knowledge — namely,  the  fat,  the  sugar,  and  the  proteids — are  of  real 
value  in  the  management  of  the  digestion  and  nutrition  of  the  infant,  and 
these  clianges  are  often  necessary  day  by  day  as  well  as  month  by  month. 
With  this  fact  impressed  upon  us,  we  can  well  see  that  no  one  mixture  will 
in  all  cases  prove  successful,  but  that  a  great  variety  in  the  percentages  of 
the  different  elements  of  the  milk  will  be  needed  in  substitute  feeding  just 
as  they  already  exist  in  maternal  feeding.  This  explains  the  diversity  of 
results  obtained  in  the  past  with  the  same  food  by  different  practitioners. 
Regarding  the  subject  from  this  point  of  view,  it  is  evident  that  there  is  no 
especial  combination  of  percentages  for  the  especial  age  of  the  infant,  for 
the  proper  nutritive  value  of  the  food  given  to  an  individual  infant  must 
be  adapted  to  that  infant's  special  stage  of  development  and  to  its  special 
powers  of  digesting  certain  percentages  and  combinations  of  percentages. 
It  has  been  frequently  observed  that  an  improper  modification  for  the  in- 
dividual may  do  much  harm  and  may  lead  to  something  more  than  indi- 
gestion,— namely,  to  such  diseases  of  nutrition  as  infantile  atrophy,  scor- 
butus, and  rhachitis, — so  that  it  is  exceedingly  important  that  the  physician 
should  understand  the  exact  modification  called  for  in  each  case  as  thor- 
oughly as  he  Avould  the  treatment  of  any  disease  in  the  individual. 

The  earlier  method  of  simple  dilutions  of  whole  milk  with  varying 
portions  of  water,  had  as  its  principle  tlie  reduction  of  the  proteids  to  a 
proportion  similar  to  that  which  occurs  in  human  milk.  The  dikition, 
however,  affected  the  fats  and  sugars  as  well,  and  the  general  effect  in  com- 
parison with  human  milk  is  seen  in  the  following  table : 


182  PEDIATRICS. 

FjH.<.  Sugar.  Proteids 

Cow's  milk -i-^W  4.75  3.50 

Cow's  milk  diluted  1  to  2 1.83  1.58  1.16 

Hmiian  milk 4.00  7.00  1.50 

Obviously,  simple  dilulions  of  whole  milk  ^vitll  water  or  any  other 
diluent,  cannot  suffice  to  produce  a  milk  resembling  mother's  milk.  Prac- 
tically, babies  seldom  do  well  on  such  mixtures,  for  if  the  milk  is  sufticiently 
diluted  to  bring  the  proteids  within  the  digestive  ability  of  the  child,  the 
fats  and  sugar  are  too  low  for  the  proper  nutrition  of  the  body. 

The  next  step  in  advance  was  the  dilution  of  creams  with  water  and 
the  addition  of  milk-sugar  to  make  up  the  deficiency  of  that  constituent. 
The  results  obtained  by  this  method  may  be  illustrated  as  follows,  using  a 
12  per  cent,  cream  as  an  example  : 

Fate.  Sugar.  Proteids. 

Cream 12  4.35  3.20 

Cream  diluted  1  to  2 4  1.45  1.06 

In  this  way  fats  and  proteids  corresponding  to  the  percentages  in 
human  milk  are  easily  obtained,  and  the  amount  of  sugar  can  be  raised  to 
any  desired  percentage  by  the  addition  of  dry  milk-sugar,  or  of  sugar 
solution  of  varying  strength  in  place  of  water. 

The  question  here  presents  itself.  What  are  the  limitations  to  tlie 
combinations  which  are  possible  by  the  employment  of  this  method  of 
diluting  creams  ?     This  we  may  calculate  by  using  the  following  formula  : 

The  percentage  of  proteids  in  a  given  mixture  equals  the  number  of 
ounces  of  cream  used  to  secm"e  the  desired  fat  percentage  multiplied  by 
the  percentage  of  proteid  in  the  cream,  and  divided  by  the  total  number 
of  ounces  of  the  mixture.  iFor  the  composition  of  creams  of  different 
strengths  see  page  168.) 

The  following  table  then  shows  the  lowest  possible  proteids  which  may 
^_Jhe  obtained  with  fat  percentages  in  our  mixtures  of  from  1  to  4.  in  which 
creams  of  from  8  to  20  per  cent,  fat  are  used  : 

Eight  per  cent,  cream  gives  with 

Fat  one  per  cent,  lowest  possible  proteids  of 0.42 

Fat  two  per  cent,  lowest  possible  proteids  of 84 

Fat  three  per  cent,  lowest  possible  proteids  of; 1.26 

Fat  four  per  cent,  lowest  possible  proteids  of 1.67 

Ten  per  cent,  cream  gives  with 

Fat  one  per  cent,  lowest  possible  proteids  of 0.33 

Fat  two  per  cent,  lowest  possible  proteids  of 0.65 

Fat  three  per  cent,  lowest  possible  proteids  of 0.98 

Fat  four  per  cent,  lowest  possible  proteids  of 1.30 

Twelve  per  cent,  cream  gives  with 

Fat  one  per  cent,  lowest  possible  proteids  of. 0.26 

Fat  two  per  cent,  lowest  possible  proteids  of 52 

Fat  three  per  cent,  lowest  possible  proteids  of 80 

Fat  four  per  cent,  lowest  possible  proteids  of 1.08 


FEEDING.  183 

Sixteen  per  cent,  cream  gives  with 

Fat  one  per  cent,  lowest  possible  proteids  of 0.20 

Fat  two  per  cent,  lowest  possible  proteids  of 0.38 

Fat  three  per  cent,  lowest  possible  proteids  of 0.57 

Fat  four  per  cent,  lowest  possible  proteids  of 0.76 

Twenty  per  cent,  cream  gives  with 

Fat  one  per  cent,  lowest  possible  proteids  of 0.15 

Fat  two  per  cent,  lowest  possible  proteids  of 0.29 

Fat  three  per  cent,  lowest  possible  proteids  of 0.43 

Fat  four  per  cent,  lowest  possible  proteids  of 0.58 

It  is  clear  from  the  above  table  that  m  simple  dilutions  of  cream  we 
are  limited  in  our  proteid  percentages.  To  get  low  proteids  with  high  fat 
percentages  in  our  mixtures,  we  must  use  concentrated  creams.  To  get 
high  proteids  with  creams  of  any  strength,  with  the  exception  of  eight  per 
cent,  cream,  we  must  add  whole  milk  or  fat-free  milk  to  supplement  the 
deficiency  of  proteids  obtained  from  the  diluted  creams. 

Materials  for  Modification  of  Milk. — Certain  materials  and  apparatus 
are  required  to  modify  milk.  To  obtain  the  required  percentag:es  of  the 
fat  resource  is  chiefly  had  to  creams  of  various  strengths ;  the  sugar  is 
supplied  by  commercial  milk-sugar ;  the  proteids  are  derived  preferably 
from  fat-free  milk,  the  caseinogen  percentage  being  obtained  from  milk  and 
the  lactalbumin  mostly  from  whey.  The  alkalinity  can  best  be  regulated 
by  freshly  prepared  lime-water.  The  water  should  be  freshly  distilled  or 
clear  water  filtered  and  boiled.  Starch,  when  used,  is  added  in  the  form 
of  a  decoction  made  from  barley,  legume,  or  oatmeal  flour. 

Definition  of  Terms. — For  the  purpose  of  uniformity  it  is  well  that  the 
meanings  of  the  terms  used  in  speaking  of  the  materials  required  for  a 
modification  of  milk  should  be  clearly  defined. 

Separated  milk  means  a  milk  from  which  the  fat  has  been  partially 
or  wholly  removed,  either  by  the  centrifuge  or  by  gravity. 

Fat-free  milk  means  a  separated  milk  which  contains  no  fat,  or  at 
least  only  a  fractional  percentage,  such  as  may  be  obtained  in  the  lowest 
quarter  of  a  quart  of  milk  Avhich  has  been  setting  six  or  more  hours. 

Cream,  means  that  which  remains  after  separated  milk  has  been  re- 
moved from  whole  milk.  It  contains  most  of  the  fat  of  the  whole  milk  and 
certain  percentages  of  all  the  other  elements  of  whole  milk.  Its  proteid 
percentage  is  only  slightly  lower  than  that  of  whole  milk,  the  higher  fat 
percentage  creams  showing  the  greater  variations,  and  none  of  the  creams 
in  ordinary  use  showing  a  proteid  percentage  as  great  as  1  per  cent,  below 
that  of  the  whole  milk  from  which  they  are  derived.  The  sugar  percent- 
age is  slightly  lower  than  in  milk,  and  the  salts  are  slightly  diminished. 
When  calculations  for  modifications  of  milk  are  being  made  from  formulae, 
it  is  necessary  to  take  into  consideration  these  variations  in  the  composi- 
tion of  cream.  A  table  showing  the  average  analyses  of  whole  milk,  creams 
of  different  strength,  fat-free  milk,  and  whey  will  be  found  on  page  168. 

Whole  milk,  therefore,  can  be  considered  a  4  per  cent,  cream. 


]g4  I'l-.DIATincS. 

Whey  means  a  milk  which  cunlains  all  iis  su^ar  and  water  while 
most  of  tlie  fat  and  all  the  caseinogen  have  been  removed.  The  fat  per- 
centage is  therefore  very  low,  and  the  proteid  percentage  as  a  whole  is 
low,  the  remaining  proteids  consisting  almost  entirely  of  lactalbumin. 

Whey  is  best  made  l^y  the  following  method  :  For  each  pint  of  whey 
needed,  take  one  quart  of  whole  fresh  milk,  or  preferably  fat-free  milk, 
heated  to  37.7°  C.  (100°  F.),  and  add  8  c.c.  (2  drachms)  of  the  essence  of 
pepsin  or  some  of  the  preparations  of  liquid  rennet.  This  will  precipitate  the 
casein  in  the  form  of  a  curd,  which  is  then  broken  up  with  a  fork,  and  the 
fluid  which  remains  is  the  whey.  This  is  strained  through  two  thicknesses 
of  boiled  cheese-cloth  and  one  thickness  of  absorbent  cotton  and  slowly 
cooled  to  a  temperature  of  10°  C.  (50°  F.\  and  kept  on  ice  until  needed.  If 
the  whey  is  to  be  mixed  with  cream,  it  must  first  be  heated  to  6o.o°  C. 
(150°F.),  in  order  to  kill  the  rennet  enzyme.  Whey  mixtures  should  not  hv 
heated  above  6<S.o°  C.  (15-")°  F.)  if  one  wishes  to  keep  safely  under  the 
coagulation  point  of  the  lactalbumin.  (For  composition  of  wliey  see 
page  168.) 

Barley  Water. — Put  four  teaspoonfuls  or  by  measure  one-lialf  ounce 
of  Robinson's  prepared  barley  into  one  quart  of  water  and  boil  for 
twenty  minutes.  Add  enough  water  to  make  up  what  has  evaporated, 
salt  and  strain  while  hot.  This  decoction  contains  about  0.75  per  cent,  of 
starch. 

Barley  Jelly. — Put  two  ounces  of  Robinson's  prepared  barley  into  one 
quart  of  water  and  boil  for  twenty  minutes.  Add  enough  water  to  make 
up  what  has  evaporated,  salt  and  strain  while  hot.  The  jelly  made  in 
this  manner  contains  about  3  per  cent,  of  starch.  Xote. — Use  a  graduate 
and  measure  as  for  fluid  ounces. 

Oatmeal  Water  and  Oatmeal  Jelly. — Oatmeal   Avater  and  oatmeal 
jelly  are  made  according  to  the  same  rales  as  in  the  case  of  barley.     An 
^-oatmeal  flour   should  be    used.     The   starch  percentage  in   the  oatmeal 
decoctions  average  0.1  per  cent,  lower  than  in  the  case  of  barley. 
The  complete  analysis  of  cereal  decoctions  is  given  on  page  168. 
Apparatus. — The  apparatus  used  in  the  home  modification  of  milk  is 
as  follows  : 

Home-Sterilizer. — If  great  precautions  are  taken  to  guard  the  milk 
and  cream,  the  mixture  made  from  them  need  not  be  pasteurized  or 
sterilized.  In  many  cases,  however,  the  physician  may  deem  it  safer  to 
heat  the  milk,  especially  when  he  is  treating  a  case  of  gastro-enteric  dis- 
turbance, or  when  in  hot  weather  it  is  necessary  to  transport  the  food  a 
lono-  distance.  If  heating  is  ordered,  a  special  apparatus  will  be  required. 
This  apparatus,  which  is  called  a  home-sterilizer,  can  be  obtained  at  the 
laboratories,  or  it  can  be  readily  devised  in  the  home  from  a  double-boiler. 
Fi^.  44  represents  the  home-sterilizer.  It  is  simply  a  tin  can  supported  on  its 
legs  so  that  it  can  be  heated  by  a  lamp,  or,  if  preferable,  the  legs  can  be 
removed  and  the  can  placed  on  a  stove. 


FEEDING 


185 


Thermometer. — The  sterilizer  lias  a  lid,  to  which  is  fitted  a  long-  llier- 
mometer,  the  lower  end  of  which  rests  within  one  of  the  tubes  containing 
the  milk,  ]\v  which  the  degree  of  heat  within  is  inchcated. 

Tubes. — The  tubes,  varying  in  number  according  to  the  number  of 
feedmgs  Avhich  are  required  in  twenty-four  hours,  are  placed  in  this  stand, 
which  can  be  lowered  into  the  sterilizer  until  the  water  therein  is  made 
to  rise  as  high  as  the  level  of  the  milk  m  the  tubes. 

Fig    44 


sterilizer  and  thermometer.        Stand  fnr  tubes 


Sterilizer  c(3vered  Av-ith  cozy  after  removal  from  heat. 


Stoppers. — The  tubes  are  stopped  with  cotton-wool  or  aluminum 
caps. 

Cozy. — The  sterilizer  is  covered  with  a  thick  cozy,  through  which  the 
thermometer  from  the  lid  passes  and  indicates  the  degree  of  heat  retained 
within  the  sterilizer  after  the  flame  has  been  removed. 

Graduate. — A  250  c.c.  (8 J  ounces)  glass  graduate,  divided  into  half- 
drachms,  will  be  needed. 

Cotton-Wool. — A  roll  of  aseptic  non-absorbent  cotton-wool  should  be 
provided. 

Milk-Sug-ar. — Milk-sugar  should  be  used.  It  should  be  a  sterilized 
product,  manufactured  by  some  reputable  chemist. 

Sugar-Measure. — A  sugar-measure,  which  holds  13.5  grammes  (3f 
drachms),  can  be  obtained  at  the  laboratories.  It  holds  approximately 
one  level  tablespoontul.  It  is  convenient  to  remember  that  our  measure 
of  milk-sugar  in  a  twenty-ounce  mixture  gives  2  per  cent,  of  sugar  in  the 
mixture. 

This  measure  obviates  the  expense  of  having  the  milk-sugar  put  up  in 
packages  by  the  apothecary,  and  is  sufficiently  exact  to  regulate  the  sugar 
percentage  in  the  mixtures  which  will  presently  be  referred  to.     It  is  well 


186  PEDIATRICS. 

to  remember,  howevrr.  that  a  pound  of  milk-sugar  contains  450.69  grammes 
(6805  grains),  and  that  if  it  is  preferred  to  order  the  sugar  in  packages  of 
13.5  grammes  (3|  drachms)  directly  from  the  apothecary,  in  place  of 
using  the  measure,  one  can  simply  tell  him  to  make  thirty-five  packages 

Fig.  45. 


Sugar-measure. 

from  the  pound,  and  the  mother  can  then  be  directed  to  use  a  package  of 
milk-sugar  instead  of  a  measureful. 

Siphon. — Finally,  a  glass  siphon.  0.6  cm.  (|-  inch)  caliber,  is  needed. 
It  may  be  made  by  bending  a  piece  of  glass  tubing  to  the  required  length 
and  angle  by  means  of  a  gas-flame.  The  end  out  of  which  the  milk  is  to 
flow  should  be  at  least  six  inches  longer  than  that  which  is  to  be  mserted 
in  the  jar.  and  to  it  should  be  attached  a  piece  of  rubber  tubmg  one  inch 
long  with  an  ordinary  clamp.  The  siphon  may  easily  be  filled  by  placing 
it  under  a  hot- water  faucet  and  then  clamping  the  rubber  end.  By  means 
of  the  clamp  the  action  of  the  siphon  may  easily  be  controlled.  Under 
no  circumstances  should  the  mouth  be  used  to  start  the  siphon,  for  by 
such  means  pathogenic  germs  are  introduced  into  the  milk.  The  rubber 
tubing  and  siphon  should  be  washed  first  m  cold  and  then  in  hot  water 
immediately  after  using. 

Method  of  Obtaining  Cream  axd  Fat-free  Milk. — In  order  to  obtain 
the  fat-free  milk  and  the  creams  of  different  percentages  the  jars  of 
milk  are  to  be  set  in  a  vessel  containing  ice  and  water  with  some  salt  in 
the  proportion  of  5  grammes  (1  teaspoonful)  to  960  c.c.  (1  quart)  of  water. 
Clean,  freshly-boiled  cotton  cloths  are  then  thrown  over  the  uncovered 
jars.  The  mouths  of  the  jars  are  kept  open  for  about  fifteen  minutes  to 
dispose  of  the  animal  heat.  The  jars  are  then  to  be  sealed  tightly,  as  is 
done  in  preserving,  and  are  left  in  the  ice-water  for  a  variable  number  of 
hours  according  to  the  fat  percentage  of  cream  desired.  Care  must  be 
taken  that  the  temperature  of  the  Avater  does  not  fall  below  1.66°  C. 
(35°  F.). 

Fig.  46  represents  a  jar  of  milk  with  the  siphon  (without  the  rubber 
end  and  clamp)  in  place.  The  first  8  ounces  removed — that  is,  the 
lowest  8  ounces — represent  what  is  practically  a  fat-free  milk.  The 
percentages  of  fat  in  the  upper  layers  will  depend  upon  the  original 
fat  percentages  of  the  milk  and  upon  the  number  of  hours  the  milk 
has  been  setting.  If  the  percentage  of  fat  in  the  milk  is  unknown. 
any  rules  for  the  estimation  of  the  percentage  of  fat  in  the  upper 
layers  under  varying  conditions  can  only  be  approximate.  If.  how- 
ever, it  is  known  that  the  milk  contains  close  to  4  per  cent,  of  fat,  we 


FEEDING. 


187 


Fig.  46. 


may  reasonably  assume  that  a  quart  of  milk  will  yield  ou  an  average 
approximately — 

TABLE  43. 

Cream,  10  per  cent,  in  the  upper  8  ounces  after  6  hours. 
Cream,  10  per  cent,  in  the  upper  11  ounces  after  8  hours. 
Cream,  12  per  cent,  in  the  upper  8  ounces  after  8  hours. 
Cream,  16  per  cent,  in  the  upper  6  ounces  after  8  hours. 
Cream,  20  per  cent,  in  the  upper    4  ounces  after  6  hours. 

If  the  milk  is  known  to  be  exceptionally  poor  m  fat,  containing,  for 
instance,  only  3  per  cent,  of  fat,  it  will  be  safer  to  take  about  2  ounces 

less  in  each  case  mentioned  above.  If  the 
milk  is  unusually  rich  in  fat,  containing  5  per 
cent,  of  fat,  it  is  safer  to  take  2  ounces  more 
in  each  case  mentioned  above.  If  the  siphon 
is  used  to  separate  the  cream  layer,  the  fat- 
free  milk  is  first  drawn  off, — that  is,  the 
lowest  8  ounces.  By  continuing  the  action 
of  the  siphon  the  middle  portion  of  the  milk 
is  then  withdrawn,  leaving  in  the  jar  4,  6,  8, 
or  11  ounces  of  the  upper  portion,  according 
to  the  percentage  of  cream  desired.  Satis- 
factory substitutes  for  the  siphon  are  Chapin's 
flat-bottomed  dipper,  or,  still  better,  a  dipper 
with  a  conical  bottom.  When  none  of  these 
mechanical  devices  is  to  be  obtained,  the 
upper  layers  may  be  carefully  poured  off. 
One  of  the  chief  difficulties  in  making  accu- 
rate modifications  at  home  lies  in  the  uncer- 
tainty as  to  what  percentage  of  fat  is  actually 
present  in  the  cream.  If  cream  of  a  definite 
strength  and  fat-free  milk  are  obtained  from 
the  milk  laboratories,  the  percentage  modification  of  milk  can  be  made 
within  very  small  limits  of  error. 

The  Calculation  of  Percentage  Combinations. — Having  obtained  the 
materials  for  the  modification, — that  is,  cream  of  10,  12,  16,  or  20  per 
cent,  strength,  fat-free  milk  to  raise  the  proteid  percentage  if  desired, 
lime-water,  boiled  or  distilled  water,  and  dry  milk-sugar, — it  now  becomes 
necessary  to  make  the  calculations  for  the  relative  amount  of  each  ingre- 
dient. This  may  be  done  in  several  ways, — either  by  the  means  of 
formulae  or  by  the  use  of  a  feeding  card,  both  of  which  methods  will  be 
described. 

The  only  objection  to  the  use  of  formulee  is  the  time  required  to  cal- 
culate the  combinations  and  the  difficulty  which  some  minds  experience 
in  dealing  with  anything  involving  even  moderately  complicated  mathe- 
matics.    It  will  also  often  be  found  when  the  computation  is  completed 


Jar  containing  milk,  cream,  and 
siphon.  C,  cream  ;  M,  milk ;  S,  si- 
phon. 


1S8  PEDIATRirS. 

tlial  IIk'  (lesiri'il  coinbiiialion  is  iiji|ii)ssil)lc  witli  lln' slreiiiith  ()!' {'rtT-aiii  used. 
We  may,  for  instance,  calculate  for  a  prescriptiou  calling  for  -i  per  cent  fat, 
6  per  cent,  sugar,  and  0.60  per  cent,  proteids.  If  we  figure  on  the  basis 
of  using  a  10  per  cent,  cream,  we  find  the  combination  impossible,  for  the 
lowest  proteid  that  can  be  obtained  from  a  10  per  cent,  cream  with  4  per 
cent,  fat  in  the  mixture  is  1.30  per  cent,  (page  LS2).  "We  next  try  a  12  per 
cent,  cream,  and  find  the  lowest  proteid  possible  is  1.08  per  cent.  Again 
we  calculate  Avitli  a  16  per  cent,  cream,  and  find  the  lowest  proteid  is  0.76 
per  cent.  Finally  we  try  a  20  per  cent,  cream,  and  find  at  last  that  it  will 
yield  both  the  fat  and  proteid  percentages  desired.  All  this  obviously  in- 
volves a  great  waste  of  time.  It  is  therefore  desirable  to  have  a  system 
by  which  it  will  be  evident  at  a  glance  what  the  combinations  are  possible 
with  a  cream  of  given  strength. 

As  any  system  relating  to  the  modification  of  milk  must  take  into 
consideration  the  composition  of  the  ingredients  used,  some  standard 
analysis  must  be  adopted.  Any  formulae  or  talDle  such  as  given  on  page 
168  presupposes  the  acceptance  of  such  a  standard.  Owing,  however,  to 
the  variation  in  the  quality  of  milk,  exception  may  be  taken  to  any 
standard  suggested.  The  analyses  which  are  there  given  are  on  the  basis 
that  the  milk  used  contains  4  per  cent,  of  fat,  4.75  per  cent,  of  sugar,  and 
3.50  per  cent,  of  proteids. 

The  composition  of  the  different  materials  used  in  the  modification  of 
milk  is  given  on  page  168. 

The  traces  of  fat  in  the  fat-free  milk  obtained  either  by  using  the 
lowest  8  ounces  of  a  c[uart  of  milk  after  it  has  been  setting  eight  or  more 
hours,  or  by  means  of  a  centrifugal  separator,  rarely  exceeds  0.05-0.1  per 
cent.,  and  can  therefore  be  excluded  in  making  the  calculations. 

The  estimation  of  a  percentage  combination  may  simply  and  quickly 
be  made  by  means  of  the  following  table,  Avhich  has  been  arranged 
and  calculated  by  Dr.  Maynard  Ladd.  The  data  given  is  printed  upon 
~a  card,  which  can  easily  be  carried  in  a  pocket-book,  and  can  there- 
fore always  be  at  hand  when  needed.  It  is  so  arranged  that  the  physician 
may  exercise  a  choice  in  the  precentage  of  cream  used,  and  can  see  at  a 
glance  whether  a  desired  combination  is  possible  with  a  cream  of  specified 
strength. 

The  formulEe  given  represent  the  combination  of  fat,  sugar  and  pro- 
teids most  commonly  cafied  for.  The  figures  express  the  number  of 
ounces  of  cream,  fat-free  milk,  lime-water  and  water,  and  the  number  of 
measures  of  sugar  required  for  20-ounce  mixtures.  Higher  or  lower  per- 
centages of  sugar  or  lime-water  can  be  obtained  in  any  of  the  formulae  by 
a  simple  calculation.  Whey  or  cereal  mixtures  may  also  be  estimated  in 
the  manner  explained  in  the  text.  The  figures  are  practically  correct. 
Sliglit  errors  due  to  the  assumption  that  the  sugar  percentage  in  the 
milk  plus  the  cream  is  the  same  as  that  of  whole  nnik  have  been  dis- 
regarded. 


FEEDING. 


189 


TABLE 

44. 

FEEDING  CARD. 

t 

Twentv-ounte  Mixtures. 

Ounces  of  Fat-free  Milk 

^ 

)ercentage  of 

Ounces  of  (Jrea 

m. 

used  vrith  Creams 

of 

Ounces  of 

ii 

§1  ^' 

^ 

^ 

*i 

-w- 

-; 

■^" 

■t^ 

.1         . 

Nl 

_. 

a 

c 

P 

J. 

l\ 

1! 

__  t- 

c  3 

J:5  a. 

0  — 

■- '       - 

ii 

^ 

JS 

-J. 

" 

iJ 

* 

'^  "* 

S  '^ 

^ 

'— 

=- 

3Q 

^ 

^ 

X 

1 

1.50 

4.50 

0.25 

5 

* 

* 

IK 

* 

* 

* 

0 

1     173.0 

2 

O.oO 

9 

1..50 

4.50 

0..50 

5 

g 

W2. 

2 

1>^ 

0 

1,^ 

1 

13^ 

16 

2 

0.70 

3 

2.00 

5.00 

0.25 

5 

* 

* 

* 

2 

* 

s'^" 

*, 

0 

17 

23i 

0.40 

4 

2.00 

5.00 

0.50 

5 

* 

3K 
3i| 

2J^ 
2K 

2  . 

* 

0 

?i 

134 

\Wa 

23^ 

0.70 

5 

2.00 

5.00 

0.75 

5 

\ 

2 

iS 

13^ 

23i 

1?A 

354 

1 

143^ 

2 

1.12 

6 

2.00 

5.50 

1.00 

5 

4 

23^ 

2 

23^ 

33I 

1 

13^4: 

2<^ 

1.36 

7 

2.50 

5.00 

0.50 

5 

* 

* 

33I 

2>2 

* 

* 

0 

% 

1 

1-5% 

234 
2<4 

0.68 

8 

2.. 50 

5..50 

0.75 

5 

* 

434 

2>| 

* 

34 
1% 

13^ 

2 

1 

143^ 

1.06 

9 

2.50 

6.00 

1.00 

.") 

5 

-Hl 

3>^ 

2% 

1 

2% 

3K 

1 

13X> 

23^ 

1.42 

10 

3.00 

6.00 

0..50 

5 

* 

*   ■ 

3^ 
3?| 

3 

* 

* 

0 

% 

1534 

2K 

0.79 

11 

3.00 

6.00 

0.75 

5 

* 

5 

3 

* 

0 

I3i 

9 

14 

-4 

1.18 

12 

3.00 

6.00 

1.00 

.', 

6 

5 

35! 

3 

0 

1 

23i 
33I 

3 

13 

2j| 

1.42 

18 

3.00 

6.00 

1.25 

.5 

6 

5 

;; 

« 

234 

^3i 

11% 

1.72 

14 

3.00 

6..50 

1..50 

.', 

6 

5 

3 

33I 

4% 

03I 

10'., 

23i 

2.04 

15 

3.00 

6.50 

2.00 

.5 

6 

5 

3 

53^ 

63^ 

7^ 

83^ 

"',.> 

9 

2.73 

16 

3.-50 

6.00 

0.50 

.") 

* 

* 

* 

W^ 

* 

* 

* 

0 

v^i 

2>^ 

0.69 

17 

3.50 

6.00 

0.75 

."i 

* 

* 

^y-i 

3% 

* 

* 

0 

1 

UK 

23^ 

0.95 

IS 

3.50 

6..50 

1.00 

.', 

* 

•5K 

43I 

33I 

* 

0 

I3i 

23i 

133i 

23^ 
23I 

1.31 

19 

3.50 

6.50 

1.25 

.T 

7 

M 

■iji 

3>l 

Yz 

1% 

3 

4 

113^ 

1.78 

20 

3..50 

6.50 

1..50 

.", 

7 

•5?l 

•13^ 

2 

33i 

43^ 

5>^ 

10 

"'34 

2.15 

21 

4.00 

6.00 

0.60 

7\ 

* 

* 

* 

4     • 

* 

* 

* 

0 

15 

23^ 

0.79 

oo 

4.00 

6.00 

0.75 

,T 

* 

* 

5 

4 

* 

* 

0 

1 

14. 

1 

1.05 

23 

4.00 

7.00 

1.00 

5 

* 

* 

5 

4 

* 

* 

1 

2 

13 

1.42 

24 

4.00 

7.00 

1.25 

5 

* 

6M 

5 

4 

* 

M 

23^ 

33^ 

nK 

■^<l 

1.78 

25 

4.00 

7.00 

1.50 

5 

8 

6% 

6-4 

6?| 

5 

4 

1 

23i 
43| 

4 

5 

10 

'^}4 

2.13 

2fi 

4.00 

7.00 

2.00 

5 

8 

5 

4 

3>^ 
6>| 
93I 

53^ 

73^ 

-!% 

23i 

2.73 

27 

4.00 

7.00 

2..50 

.5 

8 

5 

4 

734 

93i 
I23I 

I03i 

454 
1% 
IM 

2 

3.38 

28 

4.00 

7.00 

3.00 

5 

S 

5 

4 

103^ 

133^ 

13^ 

4.09 

29 

4.00 

6.00 

3.00 

5 

8 

6-4 

5 

4 

93I 

103^ 
IO3I 

1234 

1334 

1 

4.09 

30 

4.00 

5..50 

3.00 

5 

8 

63/1 

5 

4 

93^ 

I23I 

133i 

1% 

% 

4.09 

t  Thi.s  Card  may  be  obtained  of  F.  H.  Thomas  Co.  703  Boylston  Street,  Boston. 
*  Combination  impos.sible  with  percentage  of  cream  indicated. 

The  amounts  given  above  are  for  twenty-ounce  mixtures. 

For  25-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  1|. 
For  30-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  Ih 
For  35-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  If. 
For  40-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  2. 
For  45-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  2\. 

A  few  examples  may  illustrate  the  facility  with  which  a  milk  modifi- 
cation may  be  calculated  by  means  of  the  above  card. 

It  is  desired  to  give  a  baby  of  seven  months  six  feedings  of  6i  ounces 
in  the  course  of  twenty-four  hours,  the  prescription  calling  for — 

Fat , , . ,  .  ,4.00  per  cent,  (co  be  obtained  with  10  per  cent,  cream). 

Sugar ....  7.00  per  cent. 

Proteids ,    .  2.00  per  cent. 

Alkalinity ""'.00  per  cent. 

that  is,  39  ounces  of  formula  26  are  required ;  the  calculation  is  made  as 
a  matter  of  convenience  for  40  ounces.     The  process  is  as  follows  : 

Of  10  per  cent,  cream  use (8X2)  16  ounces. 

Of  fat-free  milk  use (3^  X  2)  7  ounces. 

Of  lime-water  use ' (1X2)  2  ounces. 

Of  boiled  water  use (7^X2)  15  ounces. 

Of  dry  clatose  use (2^  X  2)  4*  measures. 


190  PEDIATIUCS. 

It  may  be  desirable  to  prescribe  a  different  percentage  of  sugar  in  Ibc 
above  mixtures  than  given  in  the  table ;  for  instance,  in  the  above  ex- 
ample, 6  per  cent,  instead  of  7  per  cent.  This  is  easily  calculated  by 
referring  to  the  last  column  of  the  table,  which  gives  the  percentage  of 
sugar  contrD3uted  by  the  cream  and  fat-free  milk,  which  is  seen  to  be 
about  2.75  per  cent.  ;  the  desired  amount  is  6  per  cent. ;  therefore  dry 
sugar  must  be  added  to  the  extent  of  3.25  per  cent.,  which  may  easily  be 
estimated  by  remembering  that 

One  measure  of  dry  lactose  in  a  20-ounce  mixture  gives  2.00  per  cent,  of  sugar. 
One-half  measure  of  dry  lactose  in  a  20-ounce*mixture  gives  1.00  per  cent,  of  sugar. 
One-quarter  measure  of  dry  lactose  in  a  20-ounce  mixture  gives  0.50  per  cent,  of  sugar. 
(One  measure  holds  3|  drachms  of  lactose.) 

Use  of  Alkalies. — If  in  the  above  prescription  10  per  cent,  of  lime- 
water  had  been  desired  instead  of  5  per  cent.,  one  more  ounce  of  lime- 
water  and  one  less  ounce  of  boiled  water  should  be  taken  for  each  20 
ounces  of  the  mixture. 

The  recent  studies  of  Kerley,  Gieschen  &  Myers,  Van  Slyke,  and  others 
have  shown  that  a  uniform  five  per  cent,  of  lime-water  in  a  mixture  gives 
varying  degrees  of  alkalinity,  depending  upon  the  amounts  of  milk  and 
cream  used  and  their  percentage  of  acidity.    Whereas  the  chemical  results 
of  five  and  ten  per  cent,  of  lime-water  have  been  in  the  main  satisfactory, 
the  reason  appears  to  lie  not  in  the  neutralization  of  the  acidity  of  cow's 
milk  so  much  as  in  their  influence  upon  the  gastric  digestion  by  their  inhibi- 
tory action  upon  rennet  coagulation,  by  throwing  the  burden  of  proteid 
digestion  upon  the  intestines,  by  checking  lactic  acid  fermentation  in  the 
milk  outside  the  body  and  so  preventing  the  formation  of  the  tough  curds 
of  lactate   of  paracasein,  and   by  neutralizing  the   hyperacidity   of  the 
stomach.    Five  per  cent,  of  lime-water  has  about  the  same  effect  upon  the 
rennet  coagulation  as  one  grain  of  bicarbonate  of  soda.     The  bicarbonate 
of  soda  forms  more  porous  curds  than  the  equivalent  amount  of  lime- 
water,  but  the  latter  being  the  weaker  antacid  is  more  quickly  neutralized 
by  the  hydrochloric  acid  of  the  gastric  juice.     Bicarbonate  of  soda,  there- 
fore, is  the  more  useful  alkali  to  use  for  its  antacid  effect.    Lime-water,  on 
the  other  hand,  being  less  of  an  antacid  but  having  the  same  inhibitory 
effect  upon  the  rennet  coagulation,  leads  to  more  gradual  clotting  and 
leaves  less  alkali  behind  to  interfere  with  the  action  of  the  gastric  juice. 
The  amount  of  lime-water  or  bicarbonate  of  soda  should  therefore  be 
determined  in  part  by  the  quantity  of  milk  in  the  mixtm-e,  by  the  state  of 
digestion  and  the  object  to  be  attained.     (See  also  page  172.)     At  present 
we  can  formulate  no  general  rule  as  to  percentage  of  alkalinity  required. 
Personally,  we  have  found  in  the  early  weeks  of  life,  when  weak  formulae 
are  prescribed,  that  five  or  ten  per  cent,  of  lime-water  gives  favorable  results. 
This  relatively  high  alkalinity  decreases  in  direct  proportion  to  the  increase 
in  strength  of  the  milk  used,  which  is  coincident  with  the  increase  in  the 


FEEDIXG.  191 

infant's  powers  of  digestion,  so  that  the  uniform  employment  of  five  or 
ten  per  cent,  of  hme-water  is  not  without  reason.  Personally,  we  prefer 
lime-water  to  bicarbonate  of  soda  in  the  majority  of  cases. 

Use  of  Cereals. — Cereal  solutions  can  be  added  in  place  of  the  boiled 
water,  and  the  amount  needed  to  obtain  a  given  percentage  of  starch  cal- 
culated from  the  following  formula.  See  pages  168  and  184  for  analyses 
of  cereals : 

Desired  starch  ^  X  total  quantity  of  mixture. 
Amount  of  Cereal  in  Ounces  = 


Starch  ^  in  tlie  cereal. 

"Wliey-Mixtures  in  Infant  Feeding-. — The  employment  of  whey  as  a 
diluent  in  place  of  water  in  the  combinations  with  low  proteid  percentages 
has  proved  of  much  value  in  cases  of  difficult  proteid  digestion.  Its  use  is 
based  upon  the  facts  that  the  proteids  of  whey  are  chiefly  lactalbumin, 
lactoglobulin  and  the  nitrogenous  extractives  which  may  be  spoken  of  as 
whey-proteids.  They  are  present  to  the  extent  of  .90  to  1.00  per  cent. 
The  whey-proteids  are  soluble  proteids,  are  not  coagulated  by  rennin  or 
acids  and  are  therefore  much  easier  to  digest  than  the  other  proteids  of 
milk,  that  is,  than  the  casein  or  curd.  If,  therefore,  whey  is  added  to  a 
milk  modification  in  place  of  water,  preferably  in  the  combination  with 
low  total  proteids,  we  can  increase  the  nitrogenous  element  without  raising 
the  percentage  of  casein.  Such  mixtures  are  now  called  by  the  name  of 
"Whey-Mixtures"  or  "  Split-Proteid  Mixtures." 

It  will  help  us  to  understand  the  relative  proportions  of  whey-proteids 
and  caseinogen  in  cow's  milk  and  human  milk  to  refer  to  the  following 
table.  Variations  in  the  proportions  occur  as  has  previously  been  ex- 
plained. 

TABLE  45. 
Total  Proteids.         Whey-Proteids.  Caseinogen. 

Cow's  milk 3.50  I   (0.84  fc )  |   (2.66  fo ) 

Human  milk 1.50  f(1.00%)  i{0.50fo) 

Cow's  milk  modified  to  give. .     1.50  J   (0.37  %  )  f   (1.13  %) 

The  especial  point  to  note  is  that  the  non-coagulable  proteids,  the  whey- 
proteids,  are  proportionately  small  in  cow's  milk  and  large  in  human  milk, 
while  the  coagulable  proteid,  the  caseinogen,  is  proportionately  large  in 
cow's  milk  and  small  in  human  milk.  It  follows  that  a  modified  cow's 
milk  will  contain  relatively  much  more  casein  and  much  less  whey-proteids 
than  a  human  milk  of  the  same  total  proteid  composition.  This  doubtless 
is  one,  but  not  the  only  reason,  why  human  milk  is  so  much  more  digest- 
ible than  cow's  milk.  It  would  appear  theoretically  that  if  cow's  milk 
was  modified  so  as  to  increase  relatively  the  whey-proteids  keeping  the 
casein  low,  we  should  have  a  milk  which  would  be  more  easily  tolerated 
in  cases  of  difficult  proteid  digestion.  Practically  this  has  been  found  to 
be  true.     See  page  220. 

The  method  by  which  the  proportion  of  whey-proteids  and  casein  is 


192  PEDIATRICS. 

altered  is  not  difficult  to  understand.  The  percentages  of  fat,  proteids  and 
lime-water  are  calculated  by  the  card  as  in  the  plain  cream-mixtures. 
Three-fourths  of  the  proteid  in  the  formula  chosen  will  be  caseinogen, 
one-fourth,  whey-proteids. 

Fonuuhc  on  the  card  calling  for  0.25  proteid  give  approximately  0.20  caseinogen. 
FormuUe  on  the  card  calling  for  0.50  proteid  give  approximately  0.40  caseinogen. 
Formuhe  on  the  card  calling  for  0.75  proteid  give  approximately  0.50  caseinogen. 
Formula'  on  the  card  calling  for  1.00  proteid  give  approximately  0.75  caseinogen. 
FormuUe  on  the  card  calling  for  1.25  proteid  give  approximately  1.00  caseinogen. 
Formulfe  on  the  card  calling  for  1.50  proteid  give  approximately  1.20  caseinogen. 

To  calculate  the  additional  amount  of  whey  needed  to  make  the 
desired  whey-proteid  percentage. 

Let  W  =  number  of  ounces  of  whey  needed, 
Let  Y  =  percentage  of  whey-proteid  desired, 
Let  P  ^  pi'oteid  percentage  from  cream  and  milk, 
Let  Q  =  total  number  of  ounces  of  mixture, 

r  p    1 

Then  W   =   Q  Y  —     — 

I  -i  J 

To  calculate  the  sugar  required  beyond  that  contributed  by  cream, 
milk  and  whey, 

Let  S  ^=^  percentage  of  sugar  desired, 

Let  L  =^  number  of  measures  or  level  tablespoonfnls  of  sugar  to  be  added, 

Let  Z  =  sugar  percentage  as  given  in  last  column  of  the  feeding  card. 

Q  (S  —  Z)  —  5W 
Then  L  =  ^^^ ^^^ 

Example  .•—  R     Fat 4.00 

Sugar 7.00 

Whey-proteid 0.90 

Caseinogen ....  0. 75  . 

Lime-water 5.00 

—  20  oz.  mixture. 

Solution: — Using  16  per  cent,  cream  take  formula  23,  three-fourths  of 
the  proteid  of  which  is  caseinogen,  or  0.75  per  cent. 

Cream 5  ounces. 

Fat-free  milk ,    1  ounce. 

f  1.001 

Whey  ....   20  I  .90  —    | 13  ounces. 

L  4     J 

Lime-water 1  ounce. 

20  (7  —  1.42)  —  5X  13 

Milk-sugar ■ —  =    1.16  measures  (1^) 

40 

The  percentage  of  whey-proteids  which  can  be  had  in  a  given  com- 
bination is  limited  according  to  the  number  of  ounces  of  diluent  which 
each  formula  contains  ;  no  more  whey  can  be  added  than  there  is  water 
in  the  mixture.     For  the  method  of  making  whey  see  page  ]  84. 


FEEDING.  193 

Calculation  of  Modifications  by  Alg-ebraic  Formulae. — Westcott's 
mathematical  formulee  for  the  calculation  of  modifications  are  the  most 
elaborately  worked  out  and  are  much  more  accurate  than  those  of  earlier 
writers.  As  a  scientific  explanation  of  the  mathematical  principles  in- 
volved they  are  invaluable,  but  for  practical  use  are  unnecessarily  compli- 
cated. Those  which  are  based  upon  the  use  of  creams  and  fat-free  milk, 
however,  are  not  difficult  to  understand,  and  for  the  benefit  of  those  who 
prefer  this  system  of  calculation  may  be  concisely  stated.  We  have 
altered  Westcott's  sugar  formuUe  so  as  to  express  the  amount  of  sugar  in 
measures,  or  level  tablespoonfuls,  instead  of  in  ounces. 

Let :  F  =  prescribed  percentage  of  fat. 

S  ^=  prescribed  percentage  of  milk-sugar. 

P  =  prescribed  percentage  of  proteids. 

C  =  total  quantity  of  cream  in  omices. 

M  =  total  quantity  of  fat-free  milk  in  ounces. 

W  =  total  quantity  of  water  in  ounces. 

L  ^=  total  quantity  of  dry  sugar  in  measures. 

Q  ^  total  quantity  of  mixture. 

a  =  known  percentage  of  fat  in  cream.      (See  page  168.) 

b  =  known  percentage  of  proteids  in  cream.      (See  page  168.) 

b''^  known  percentage  of  proteids  in  fat-free  milk.      (See  page  168.) 

Then 

QF 
Ounces  of  cream  (C)  =  — — 

Q  P  —  b  C 

Ounces  of  fat- free  milk  (M)  =  rj 

^r                .'      -11              n^       QS-4.75  (M -^  C) 
Measures  ot  milk-sugar  (L)  := 77^ • 

Ounces  of  water  ( W)  =--  Q  —  (C  +  M) 

It  is  a  distinct  advantage  to  work  with  creams  and  fat-free  milk,  the 
lowest  quarter  of  a  quart  of  milk  which  has  set  eight  or  more  hours,  instead 
of  with  creams  and  whole  milk,  as  the  fat-free  milk  may  be  had  from  the 
same  quart  of  milk  from  which  the  cream  is  obtained ;  otherwise  an  extra 
quart  of  milk  must  be  provided  to  furnish  the  whole  milk.  The  amount 
of  fat  in  the  lowest  cparter  is  so  small  that  it  may  be  disregarded. 

The  Mixing-  of  Milk  and  its  Administration. — The  principles  of  the 
modification  of  milk  which  have  been  described  need  only  be  understood 
by  the  physician.  The  directions  which  are  given  to  the  mothers  can  be 
very  simply  stated,  and  require  only  moderate  intelligence  to  carry  out. 
She  is  told  to  take  the  required  number  of  ounces  of  cream,  fat-free  milk 
and  lime-water  and  to  mix  them  in  a  large  sterilized  vessel.  The  milk- 
sugar  is  then  measured,  and  boiled  or  distilled  water  added  up  to  the 
amount  called  for.  As  the  milk-sugar  does  not  go  into  solution  readily  in 
the  cream  and  milk,  the  precaution  of  dissolving  it  in  the  water  first  is 

13 


194  PEDIATRICS. 

important.  The  sugar  solution  thus  obtained  is  added  to  the  mixture  of 
cream,  fat-free  milk  and  lime-water  and  the  whole  is  poured  into  another 
vessel,  once  only,  to  insure  thorough  admixture  of  all  the  ingredients.  It  is 
then  divided  into  as  many  nursing  bottles  as  there  are  feedings  in  the 
twenty-four  hours,  each  bottle  containing  the  prescribed  amount  for  one 
feeding.  The  bottles  are  then  tightly  stoppered  with  clean  absorbent 
cotton  and  placed  at  once  in  the  ice  chest. 

If  the  milk  is  to  be  pasteurized,  the  bottles  are  placed  in  a  sterilizer 
filled  Avith  cold  water  up  to  the  level  of  the  milk.  The  thermometer  is 
placed  in  one  of  the  bottles  of  milk,  and  the  temperature  of  the  water  may 
be  raised  to  about  3°  F.  above  that  at  which  the  milk  is  to  be  pasteurized, 
covered  with  a  hood  and  kept  at  a  constant  point  for  20  to  30  minutes. . 
The  bottles  are  then  removed,  cooled  quickly  in  running  water  and  placed 
on  ice. 

Before  each  feeding  the  milk  is  heated  again  in  hot  water  until  its  tem- 
perature has  been  raised  to  100°  F.,  the  stopper  is  removed  and  a  clean, 
sterile  nipple  applied.  The  milk  may  be  kept  warm  by  wrapping  the 
bottle  in  a  napkin.  As  a  rule  fifteen  to  twenty  minutes  are  sufficient  to 
allow  for  the  nursing  period. 

The  bottle  should  invariably  be  held  by  the  nurse  or  mother  in  such  a 
way  that  the  neck  is  kept  constantly  filled,  the  baby  remaining  on  its  back 
in  its  crib.  The  custom  of  propping  the  bottle  up  so  as  to  leave  the  nipple 
Avithin  reach  of  the  child  should  be  absolutely  forbidden. 

Especial  care  should  be  taken  to  explain  to  the  mother  what  is  meant 
by  "  cream  ""  and  "  fat-free  "'  milk,  and  in  directing  her  as  to  the  number  of 
quarts  of  milk  to  be  ordered  to  secure  the  c{uantity  of  cream  needed.  She 
should  be  impressed  with  the  fact  that  the  number  of  ounces  of"  cream" 
removed  from  each  quart  of  milk  includes  usually  w^hat  is  visible  as  cream, 
and  also  a  certain  number  of  ounces  of  milk  beneath  the  cream  line. 
Great  errors  in  modification  arise  from  neglect  of  this  precaution.    Page  187. 

A  graduate  and  milk  thermometer  are  the  only  apparatus  which  is 
'essential,  in  addition  to  the  nursing  bottles.  A  sugar  measure  and  a  steril- 
izer are  convenient  to  have.  A  double  boiler  will,  however,  serve  the 
purpose  of  pasteurization.  The  nipples  vary  greatly  in  shape.  The  essen- 
tial point  is  to  provide  one  which  will  not  collapse,  can  be  easily  turned 
inside  out  and  scrubbed,  and  which  has  a  perforation  of  the  size  appro- 
priate for  the  individual  case.  Too  large  or  too  small  holes  are  equally 
objectionable.  Many  nurses  prefer  to  buy  blind  nipples  and  pierce  holes  in 
them  with  red-hot  needles.  In  this  way  one  soon  learns  the  size  AA'hich  is 
best  suited  to  the  case.  The  nipple  should  be  scrubbed  with  borax  and 
washed  in  boiling  water  after  each  nursing,  and  then  kept  in  a  solution  of 
boric  acid.  It  is  wise  to  keep  several  nipples  in  use,  so  that  the  bal^y  may 
not  become  fixed  in  its  preference  for  any  particular  one.  Nipples  with 
tubings  attached  are  a  great  source  of  danger,  owing  to  the  impossibility  of 
keeping  them  clean. 


FEEDING.  195 

Method  of  Calculating-  Percentages  from  Kno-wn  Mixtures. — It  is 
often  desirable  to  determine  from  a  given  mixture  of  cream,  milk,  lime- 
water,  water  and  milk-sugar,  the  percentages  of  fat,  sugar  and  proteids,  in 
order  that  we  may  form  an  intelligent  idea  of  the  strength  of  the  food 
which  an  infant  has  been  receiving.  This  may  of  course  be  done  by  the 
use  of  the  same  formulae  given  above,  by  substituting  the  known  values 
and  clearing  the  equation. 

Simpler  formulte  may,  however,  be  employed  and  the  problem  made 
less  complex,  by  assuming  the  proteid  percentage  of  the  cream  plus  the 
milk  to  be  ec|ual  to  that  of  whole  milk,  the  sugar  percentage  of  the  cream 
plus  the  milk  to  be  ec^ual  to  that  of  whole  milk,  and  the  value  of  a  measure 
of  dry  milk-sugar  to  be  ec{ual  to  2  per  cent,  in  each  20  ounces  of  food. 
These  assumptions  lead  to  slight  errors  in  the  results,  on  the  plus  side,  but 
they  are  not  sufficiently  large  to  impair  the  value  of  the  calculation. 

Let: 

C  =  number  of  ounces  of  cream  used, 

M  ==  number  of  ounces  of  fat-free  milk  used, 

L  =  number  of  measures  or  level  tablespoonfuls  of  dry  sugar  used, 

Q  =  total  quantity  of  mixture, 


Then  the 


^  ,                            C  X  fat  percentage  of  cream 
Fat  percentage  =  


Proteid  percentage  ^ 
Sugar  percentage  = 


Q 

3.50  (C  +  M) 

Q 

4.75  (C  +  M)  ^  40  L 


Q 


Slight  but  unimportant  errors  arise  in  connection  with  these  formulae 
in  assuming  the  percentages  of  proteids  and  sugar  in  the  milk  and  cream 
to  be  the  same  as  in  whole  milk.  These  errors  may  be  disregarded,  as 
by  so  doing  the  formula  are  greatly  simplified. 

If  whole  milk  is  used  in  place  of  fat-free  milk,  M  will  stand  for  the 
number  of  ounces  of  whole  milk  used,  and  we  must  add  to  the  fat  per- 
centage contributed  by  the  cream,  the  fat  percentage  contributed  by  the 
whole  milk,  which  would  be 

M  X  4 
Fat  percentage  in  whole  milk  r^  — -~— 

Q 

The  fat  percentage  in  the  cream  used  must  be  estimated  by  referring 
to  the  table  on  page  187,  by  which  one  may,  by  learning  from  the  mother 
the  number  of  hours  the  milk  has  stood  and  the  cpantity  removed  from 
the  top,  roughly  calculate  the  fat  percentage  of  the  cream  used. 

Example. — A  mother  is  making  a  mixture  calling  for  7|  ounces  of 
cream,  IJ  ounces  of  fat-free  milk,  U  ounces  of  lime-water,  19J  ounces  of 
boiled  water  and  3|  measures  of  dry  milk-sugar.     This  makes  a  30-omice 


196 


PEDIATRICS. 


mixture.  The  cream  is  obtained  by  taking  the  top  8  ounces  from  a  quart 
of  milk  which  has  stood  eight  or  more  hours,  which  yields  12  per  cent, 
fat.     The  calculation  is  then  made  as  follows  : 

7.5  X  12  ^  90 
30      30 
3.50  (7.5  +  1.5)     31.5 


—  =-3  per  cent.  fat. 


30 


30 


1.05  per  cent,  proteids. 


4.75  (7.5  +  1.5)  +  40  X  3.5  __  42.75  +  140 


6.09  sugar  jjercentage. 


30  30 

If  whole  milk  is  used  in  place  of  fat-free  milk,  the  percentage  of  fat 
contributed  by  the  whole  milk  is 

1.5  X  4 


30 


=  .2 


and  the  fat  percentage  in  the  mixture  is 

3  +  .2 --=3.2  per  cent. 

Rules  for  Feeding-, — Equally  important  with  the  question  of  the  com- 
position of  the  food  is,  as  in  the  case  of  breast  feeding,  the  regulation  of 
the  number  of  feedings,  the  intervals  between  feedings  and  the  quantity  at 
each  feeding.  The  following  table  gives  these  rules,  together  with  the 
appropriate  modification  at  different  ages,  both  in  the  plain  cream  mixt- 
ures and  the  whey-proteid  mixtures.  It  should  be  strictly  borne  in  mind 
that  these  data  apply  only  to  the  average  healthy  infants.  They  do  not  nec- 
essarily hold  in  cases  of  disturbed  digestion,  as  will  be  explained  later. 
They  are  given  here  only  as  a  general  guide,  and  should  be  varied  accord- 
ing to  the  individual  requirements. 

TABLE  46. 

Tlieoretical  Basis  for  Feeding  a  Healthy  Infant. 


Age 

Fat 

Sugar 

Pro- 

Protei( 
Whey 
Pro- 
teids 

is  if  split 

Am.  at  each 
feeding  in 

Intervals 
between 

Number  of 
feedings  in 

- 

.  teids 

Caseinogen 

ozs. 

e.c. 

hours 

24  hours 

Premature  

1.00 

4.00 

0.25 

0.25 

0.25 

M 

3.7.5- 
22.50 

1-U 

24-18 

1.50 

4.50 

0.25 

0.50 

0.25 

At  term 

2.00 
2.50 

5.00 
5.50 

0.50 
0.50 

0.50 
0.50 

0.25 
0.25 

1 

80 

45 

2 

2 

10 

End  of  2nd  week 

10 

End  of  3rd  Meek.  . 

3.00 

6.00 

0.75 

0.75 

0.25 

2 

60 

2 

9 

End  of  4th  week. . 

3.50 

6.50 

1.00 

0.75 

0.50 

2k 

75 

2 

8 

End  of  6th  week . . 

400 

7.00 

1.00 

0.90 

0.60 

3 

90 

•i\ 

S 

End  of  8th  week .  . 

4.00 

7.00 

1.25 

0.90 

0.75 

'6h 

105 

2.} 

7 

End  of  12th  w^eek. 

4.00 

7.00 

1.50 

0.90 

1.00 

'  4 

120 

21 

7 

End  of  4th  month  . 

4.00 

7.00 

1.50 

0.75 

1.25 

4.', 

135 

;] 

6 

End  of  oth  month 

4.00 

7.00 

1.75 

5i 

165 

3 

6 

End  of  6th  month  . 

4.00 

7.00 

2.00 

6 

180 

3 

6 

End  of  8th  month 

'  4.00 

7.00 

2.. 50 

7 

210 

3 

6 

End  of  9th  month . 

4.00 

7.00 

3.00 

8 

240 

3 

6 

End  of  10th  month 

4.00 

6.00 

3.00 

8 

240 

3 

6 

End  of  11th  month 

4.00 

5.00 

3.00 

10 

300 

3 

5 

End  of  12th  month 

j  4.00 

4.75 

3.50 

10 

300 

1         ^ 

5 

The  data  given  above  are  simply  a  guide  to  the  rules  for  feeding  of  the  average 
healthy  baby  ;  they  are  only  approximate  and  not  intended  to  be  followed  in  cases  of 
difficult  feeding,  without  due  consideration  to  the  individual  requirements.  Some  in- 
fants require  from  \  to  1  ounce  more  than  given  in  the  schedule. 


FEEDING.  197 

The  first  month  being  the  most  critical  period  for  the  infant's  nutrition, 
as  it  is  tlie  time  when  the  ecfuilibrium  of  its  metabolism  is  being  estab- 
lished and  its  chance  for  life  is  least,  especial  interest  should  be  attached 
to  the  series  of  careful  investigations  made  at  the  Children's  Hospital  in 
St.  Petersburg  by  Ssnitkin  to  determine  the  amount  of  food  which  should 
be  given  in  the  first  thirty  days  of  life.  As  the  result  of  these  investigations 
he  deduces  the  rule,  "  the  greater  the  weight  the  greater  the  gastric 
capacity."  Ssnitkin's  general  results  show  that  one  one-hundredth  of  the 
initial  tveight  should  he  taken  as  the  figure  with  ichich  to  begin  the  computa- 
tion^ and  to  this  should  be  added  one  gramme  for  each  day  of  life. 

Illustration  of  Ssnithn's  rule  to  aid  in  adjusting  the-food  to  especially  difficult  cases  in  the 

first  thirty  days. 

Amount  at  each  Feeding. 
Initial  Weight,  Early  Days.  At  15  Days.  At  30  Days. 

3000  grammes ....        30  grammes.        30  +  15  =  45  gramme.s.  30  +  30  =  60  grammes. 

(About  1  ounce.)        (About  li- ounces.)  (About  2  ounces.) 

4500  grammes ... .       45  grammes.       45  +  15  =  60  grammes.  45 +30  =  75  grammes. 

(About  1 1  ounces.)       (About  2  ounces.)  (About  2}  ounces.) 

6000  grammes ....        60  grammes.       60  +  15  =  75  grammes.  60  +  30  =:  90  grammes. 

(About  2  ounces. )         (About  2^  ounces.)  (About  3  ounces.) 

It  is  wiser  always  to  accomplish  first  the  proper  digestion  of  the  food, 
even  if  there  is  no  gain  in  weight,  and  then,  Avhen  once  the  infant  is 
digesting  well,  to  increase  the  amount  of  the  percentages  of  the  different 
elements.  At  times  when  the  infant  is  digesting  well,  and  even  gaining,  it 
will  suddenly  cry  so  hard  and  with  such  evident  hunger,  that  an  imme- 
diate increase  in  the  amount  of  its  food  is  not  only  indicated  but  demanded, 
no  matter  wdiat  its  age  or  weight.  In  these  eases  the  stomach  has 
probably  grown  rapidly  and  out  of  its  normal  proportion  to  the  age  and 
size  of  the  child,  and  a  larger  supply  of  food  is  what  is  needed. 

It  has  been  found  by  experience,  that  it  is  not  good  practice  to  start  a 
new-born  infant  upon  modified  milk  of  the  same  composition  as  human 
milk.  The  most  frecfuent  mistake  made  is  to  give  a  milk  of  too  high  per- 
centages. If  there  is  any  one  rule  which  is  more  important  than  others, 
it  is  to  begin  the  feedings  on  low  modifications,  regardless  of  age,  and 
then,  gradually  advancing  one  element  after  another,  to  increase  the 
strength  until,  by  the  eleventh  or  twelfth  month,  the  infant  is  getting 
whole  milk.  The  rapidity  with  which  this  can  be  done  varies  according 
to  the  idiosyncrasies  of  the  infant.  Each  child  is  a  problem  by  itself,  and 
no  greater  mistake  can  be  made  than  to  assume  that  all  babies  of  an  age 
require  the  same  strength  of  food.  There  are  cases  in  which  whole  milk 
cannot  be  digested  until  the  fourteenth  or  fifteenth  month,  or  even  later. 
The  quantity  of  food  taken  often  varies  within  wide  limits,  so  that  no 
arbitrary  rules  of  feeding  should  be  the  standard  by  which  to  judge  an 
infant's  progress,  but,  as  has  been  stated,  one  must  be  guided  by  the  state 
of  its  digestion  and  weight  development.    If  a  baby  at  birth  is  started  on  a 


198  PEDIATRICS. 

carefully  modified  milk  made  from  fresh,  clean  cow's  milk,  and  if  it  is 
intelligently  observed,  one  will  rarely  fail  to  pull  it  successfully  through  its 
critical  first  year,  but  there  are  difficult  cases  which  require  much  patience 
and  careful  variations  in  the  composition  of  the  milk  from  time  to  time. 

For  the  first  twenty-four  to  thirty-six  hours,  a  drachm  or  two  of  a  five 
per  cent,  lactose  solution,  every  hour  and  a  half  or  two  hours,  usually 
suffices.     It  is  then  wise  to  begin  at  once  on  a  modified  milk. 

The  percentage  of  fat  should  be  from  1.5  to  2  during  the  first  week, 
increasing  it  to  2.50  in  the  second  week.  By  the  end  of  the  third  week 
3,00  per  cent,  fat  may  be  tried,  and  at  the  end  of  a  month  it  may  be  possible 
to  give  a  3.50  per  cent.  fat.  It  is  often  advisable  not  to  start  the  child  on 
a  4.00  per  cent,  of  fat  until  the  sixth  or  eighth  week.  Higher  than  this 
it  is  usually  not  wise  to  go. 

The  sugar  percentage  can  be  pushed  up  even  more  rapidly  than  the 
fat.  We  begin  with  a  5.00  per  cent,  in  the  second  week,  raise  it  to  a  6.00 
per  cent.,  and  by  the  end  of  the  first  month  to  7.00  per  cent.,  which 
represents  the  maximum. 

The  management  of  the  proteids  presents  the  greatest  difficulty.  It  is 
disastrous  to  give  too  high  proteids,  and  it  is  dangerous  to  keep  them  too 
low  for  too  long  a  period.  Most  physicians  err  in  giving  percentages  at  the 
beginning  so  high  as  to  cause  both  disturbances  of  the  digestion  and  nutri- 
tion. Those  of  us  who  appreciate  how  great  is  the  danger  of  high  proteids 
have  to  guard  against  the  habit  of  keeping  them  low  for  so  long  that  the 
nutrition  of  the  child  suffers.  Obviously  success  comes  most  frequently 
to  him  who  can  discriminate  nicely  between  the  two  extremes.  The  abihty 
of  infants  to  digest  the  proteids  of  milk  varies  so  greatly  that  one  hesitates  to 
give  definite  statements  as  to  the  desirable  percentages  at  different  ages.  It 
is  safest  to  begin  low  and  increase  very  gradually  by  percentages  not 
greater  than  0.25.  A  percentage  of  0.50  ^^dll  last  for  a  Aveek  or  two.  In 
jthe  third  week  it  may  be  raised  to  0.75  per  cent.,  and  if,  at  the  end  of  a 
month,  1.00  has  been  reached,  Ave  are  doing  very  well.  For  the  second 
and  third  months  1.25  per  cent.,  and  1.50  for  the  fourth  month  are 
generally  sufficient.  Tavo  per  cent,  of  proteids  at  the  fifth  or  sixth  month 
is  desirable,  if  it  can  be  digested,  and  is  continued  until  the  eighth  or  ninth 
month.  Avhen,  in  healthy  babies,  it  is  Avell  to  add  barley-Avater,  or  oat- 
Avater,  in  place  of  the  boiled  water  Avhich  is  used  as  the  diluent.  This 
serves  to  break  up  the  curds,  and  also  proAides  the  element  of  starch 
Avhich  the  child  at  this  age  begins  to  need  for  its  proper  nutrition,  but  does 
not  lessen  the  necessity  of  careful  regulation  of  the  other  ingredients.  The 
thickness  of  the  barley-AA-ater  and  oat-Avater  can  then  be  gradually  in- 
creased, Avhile  the  proteids  are  raised  to  2.5  and  then  3  per  cent.  The 
higher  the  proteids  are  raised  the  less  is  the  amount  of  the  diluent,  so  that 
unless  the  cereal  solution  is  increased  in  strength,  there  Avill  be  a  continual 
decrease  in  the  percentage  of  starch  which  is  contained  in  the  modifica- 
tion.    With  the  increase  in  the  amount  of  starch  the  percentage  of  milk- 


FEEDING.  199 

sugar  is  gradually  diminished  to  that  of  whole  milk,  and  the  question  of 
feeding  then  becomes  that  of  the  second  year  of  life. 

The  amounts  at  each  feeding,  the  intervals  and  number  of  feedings 
need  no  further  explanation  than  that  given  in  the  above  table,  except  to 
impress  upon  the  physician  that  they  are  only  approximate,  and  in  some 
cases  more,  in  others  less,  than  the  quantities  suggested  will  be  found 
desirable.  No  radical  increase  in  the  c{uality  beyond  that  recommended 
can  be  made,  however,  without  running  the  risk  of  causing  dilatation  of 
the  stomach.  Dilatation  of  the  stomach  is  a  very  common  result  of  over- 
feeding and  often  the  primary  cause  of  indigestion  and  may  exist 
independently  of  any  stenosis  of  the  pylorus. 

Diflacult  Cases  of  Feeding-. — The  cases  of  feeding  which  give  us  the 
greatest  difficulty  are  not  as  a  rule  those  which  have  been  fed  artificially 
with  accurate  modifications  from  the  beginning,  but  are  those  whose  diges- 
tion, both  gastric  and  intestinal,  has  been  abused  by  unintelligent  use  of 
proprietary  foods,  or  by  improper  modifications  of  milk.  It  is  not  uncom- 
mon to  see  infants  several  months  old  weighing  less  than  when  born.  In 
some  of  these,  especially  in  the  cases  of  infantile  atrophy,  obscure  changes 
have  taken  place  which  interfere  with  the  assimilation  of  food.  One  can 
never  tell  in  advance  which  of  these  cases  will  resist  all  efforts  to  re- 
establish normal  digestion  and  nutrition,  or  which  ones  Avill,  after  months 
of  patient  work,  yield  to  treatment.  Many  desperate  and  apparently  hope- 
less cases  may  be  saved,  but  our  failures  are  sufficiently  great  to  impress 
upon  our  minds  with  painful  clearness  the  importance  of  prophylaxis, 
and  an  appreciation  of  the  principles  of  infant  feeding,  so  that  by  more 
intelligent  and  thoughtful  care  in  the  early  weeks  and  months,  the  serious 
consequences  of  improper  feeding  may  be  avoided. 

The  use  of  whey-cream  mixtures  in  these  severe  cases  of  malnutrition 
with  indigestion  is  to  be  strongly  recommended,  and  has  been  tried  by  us 
in  over  four  hundred  cases,  part  of  which  have  been  reported,  with  better 
results  than  by  the  use  of  the  plain  cream  mixtures.  If  the  fats  are  started 
irrespective  of  the  age  of  the  child,  at  2  per  cent.,  the  sugar  at  5  per  cent., 
and  the  caseinogen  at  0.25  per  cent.,  the  whey-proteids  can  be  rapidly 
increased  to  the  maximum  of  0.90  per  cent.  This  weak  mixture  should 
be  continued  until  the  symptoms  of  indigestion  have  disappeared  or  been 
greatly  alleviated.  This  is  the  first  object  to  be  sought,  even  at  the  cost  of 
further  loss  of  weight.  It  provides  the  element  of  rest  which  is  essential 
to  the  restoration  of  the  normal  functions  of  the  digestive  apparatus.  We 
may  then  by  slow  but  progressive  changes  in  the  percentages  of  the  fats, 
sugar  and  caseinogen,  and  by  increase  in  the  quantity  of  food,  direct  our 
efforts  towards  the  reconstruction  of  the  tissues,  keeping  in  mind,  as  the 
limits  to  be  attained,  the  theoretical  basis  of  feeding  given  above. 

Occasionally,  in  very  difficult  cases,  in  addition  to  the  modification  of 
the  milk  along  the  lines  which  have  been  indicated,  the  peptonization  of 
the  mixture  is  a  valuable  expedient,  as  a  temporary  measure,  principally 


200  PKDIATI'.ICS. 

to  lessen  the  tax  on  the  function  of  gastric  digestion.  For  these  purposes 
the  peptonizing  tubes,  put  up  by  manufacturing  chemists,  are  very  con- 
venient to  use.  It  is  a  fair  statement  to  make,  however,  that  the  more 
famihar  and  experienced  one  becomes  with  the  principles  of  percentage 
modification  of  milk  and  of  infant  feeding  in  general,  the  less  frequently 
Avill  one  resort  to  peptonization. 

There  are  certain  symptoms  pointing  especially  to  gastric  indigestion, 
such  as  vomiting  of  food  or  water,  belching  gas,  a  coated  tongue  and  sour 
breath.  Symptoms  such  as  colic,  flatulence,  abdominal  distention,  diar- 
rhoea, constipation,  and  stools  with  curds,  mucus  or  blood,  point  to 
intestinal  derangements.  Sometimes  it  is  one  element,  sometimes  several, 
which  either  cause  or  aggravate  these  symptoms ;  we  cannot  always  deter-, 
mine  which  one  is  responsible.  As  a  rule  a  sour  breath  and  vomiting  of 
strongly  acid  stomach  contents  indicate  too  high  fats,  but  excessive  sugar 
or  proteids  may  produce  the  same  results.  Vomiting  very  shortly  after 
feeding  and  regurgitation  is  often  due  to  overdistention  of  the  stomach 
from  too  large  a  quantity  of  food.  Colic,  and  stools  with  curds,  usually 
indicate  too  high  proteids,  sometimes  too  high  fats.  Constipation  may  be 
due  to  too  low  fats,  or  to  milk  which  in  its  total  solids  or  twenty-four  hour 
amount  is  below  that  Avhich  is  needed  by  the  infant.  If  there  is  no  indi- 
gestion, a  failure  to  gain  in  weight  is  probably  due  to  the  fact  that  the  milk 
combination  as  a  whole  is  too  weak,  or  the  quantity  given  in  the  twenty- 
four  hours  is  deficient.  On  the  other  hand,  too  much  of  a  proper  modifi- 
cation, or  too  frequent  feedings,  are  often  responsible  for  retardation  of 
the  weight  development. 

Finally,  it  is  important  to  remember  when  judging  of  results,  that 
failures  in  feeding  are  not  always  due  to  the  food  itself.  There  are  a  large 
number  of  causes,  quite  independent  of  the  milk  and  its  modifications, 
which  are  responsible  for  conditions  which  are  characterized  chiefly  by 
astric  and  intestinal  disturbances  and  loss  of  weight.  Cleft  palate,  ade- 
noids, the  various  forms  of  stomatitis  and  difficult  dentition  are  many  times 
the  causes  of  the  refusal  of  part  or  all  of  a  feeding  and  for  variabilities  in 
appetite  and  freedom  of  nursing  which  may  hastily  be  attributed  to  the 
milk  itself.  Too  rapid  and  frequent  nursing,  or  too  large  quantities  at  a 
feeding,  may  be  followed  by  vomiting,  which  may  unreasonably  be  laid  to 
the  bad  quality  of  the  milk  or  to  its  percentage  combination.  Again, 
vomiting  and  diarrhoea  and  loss  of  weight  may  be  wholly  symtomatic  of 
either  acute  or  chronic  diseases.  Many  of  the  forms  of  anaemia  and  leu- 
kemia, bacterial  invasion  of  various  parts  of  the  body,  chronic  diseases, 
such  as  tuberculosis  and  syphilis,  autointoxications,  malformations  of  the 
gastro-intestinal  tract,  inhalations  of  poisoning  from  arsenic,  sewer  gas, 
carbon  monoxide,  and,  not  least  by  any  means,  unhygienic  surroundings 
and  neglect,  are  all  to  be  included  as  possible  factors  in  the  production  of 
indigestion  and  malnutrition  when  a  case  is  first  seen.  In  any  of  these 
instances  the  regulation  and  adaptation  of  the  food  becomes  the  first  indi- 


FEEDING. 


201 


cation  of  treatment,  but  the  prognosis  is  always  that  of  the  exciting  cause, 
and  all  efforts  at  feeding  may  prove  futile.  In  pure  feeding  cases,  how- 
ever, in  which  the  indigestion  and  mahiutrition  are  directly  dependent  upon 
violation  of  the  rational  dietetics  of  infancy,  there  is  no  case,  not  actually 
moribund,  that  is  not  worth  the  effort  to  save,  and  in  a  great  majority  of 
these  cases  one  may  justly  take  a  most  hopeful  view  as  to  the  ultimate 
prognosis. 

Caloric  Value  of  Milk  Modifications. — The  following  figures  give  the 
caloric  value  of  the  milk  modifications  shown  in  the  feeding  card.  We  do 
not  believe  that  the  caloric  value  of  a  food  is  the  only  point  of  importance 
in  infant  feeding.  Formula  18,  calling  for  fat  3.50,  sugar  6.00,  proteids  1.00, 
has  a  slightly  higher  caloric  value  than  Formula  15,  calling  for  fat  3.00, 
sugar  6.50,  proteid  2.00,  and  yet  the  low  proteid  percentage  in  the  former 
makes  it  a  much  more  digestible  food  than  the  latter,  and  one  on  which 
an  infant  with  weak  digestion  will  be  more  likely  to  gain.  It  is  of  value  to 
check  percentage  feeding  with  a  knowledge  of  the  caloric  value  of  the  food 
ingested.  We  are,  however,  unable  to  state  that  a  child  of  a  certain 
number  of  months  requires  a  definite  number  of  calories.  The  number  of 
calories,  like  the  percentages  of  the  ingredients,  varies  according  to  the 
pathological  conditions  present.  Future  study  of  feeding  cases  may  enable 
us  to  draw  more  definite  statements  in  regard  to  the  caloric  needs  of 
infants  m  healthy  and  diseased  conditions  than  we  now  believe  to  be 
possible.     (See  Table  46,  page  186,  for  the  formulae  referred  to.) 


Formula  Xo.  Calories. 

1 334 

2 344 

3 401 

4 411 

5 421 

6 452 

7 458 

8 488 

9... 520 

10 545 

11 555 

12 566 

13 576 

14 606 

15 '. 626 


Formula  No.  Calories. 

16 591 

17 .' 601 

18 631 

19 642 

20 653 

21 642 

22 648 

23 690 

24 •.  710 

25 720 

26 741 

27 762 

28 782 

29 741 

30 720 


Sources  of  Error  in  Milk  Modification  and  Percentage  Feeding. — 
There  are  certain  sources  of  error  and  difficulties  in  the  modification  of 
milk  and  percentage  feeding  which  should  be  appreciated  and  guarded 
against.  The  danger  of  using  a  contaminated  milk,  especially  in  hot 
weather,  has  already  been  emphasized.  The  most  careful  modification  of 
impure  milk  Avill  usually  lead  to  serious  disturbances  of  digestion  and 
nutrition.     The  poor  quality  of  the  general  milk-supply  is  responsible  for 


202  PEDIATRICS. 

much  of  the  prejudice  against  substitute  feeding  and  tends  to  encourage 
the  use  of  proprietary  foods.  One  of  the  principal  advantages  of  labora- 
tory feeding  lies  in  the  purity  of  the  material  used. 

The  next  greatest  source  of  error  is  the  liability  to  mistakes  in  making 
the  modifications.  These  are  dependent  upon  the  variations  in  the  com- 
position of  the  milk  and  cream  which  is  used.  For  example,  a  physician 
may  calculate  upon  a  4  per  cent,  fat  mixture,  based  upon  the  use  of  a  10 
per  cent,  cream.  This  requires  8  ounces  of  cream  for  a  20-ounce  mixture. 
The  cream  is  obtained  by  using  the  top  11  ounces  of  a  quart  of  milk  which 
has  stood  over  night  (page  187).  The  mother  may  misunderstand  the 
directions,  and,  in  the  belief  that  all  creams  are  of  the  same  strength,  may 
draw  off  the  top  4  ounces  of  cream  from  each  of  two  quarts  of  milk, 
in  this  way  obtaining  8  ounces  of  cream.  Such  a  cream  would,  however, 
contain  20  per  cent,  of  fat  on  the  average,  instead  of  the  10  per  cent,  on 
which  the  calculation  is  based,  so  that  the  resulting  fat  percentage  in  the 
mixture  will  be  8  per  cent.,  instead  of  the  desired  4  per  cent.  This  mis- 
take is  not  a  theoretical  one,  as  we  have  known  it  to  occur  repeatedly, 
with  disastrous  effects  upon  the  infant's  digestion.  It  is  necessary,  there- 
fore, to  explain  very  fully  just  how  many  ounces  of  top  milk  one  means  by 
"  cream," 

Similar  mistakes  occur  when  the  milk,  instead  of  containing  4  per  cent, 
of  fat  to  begin  with,  has  a  fat  percentage  of  3  or  6.  The  cream  in  the 
different  layers  in  such  cases  do  not  follow  the  rules  given  on  page  187.  The 
only  way  to  guard  against  such  an  error  is,  when  the  results  of  feeding  are 
not  satisfactory,  to  have  either  the  milk  or  the  cream  which  is  separated 
analyzed  from  time  to  time,  as  to  its  composition,  and  to  correct  the  modi- 
fication according  to  the  results.  The  greater  accuracy  of  laboratory 
modifications  over  home  modifications,  which  is  shown  by  Edsall's  anal- 
yses, lies  largely  in  the  fact  that  the  composition  of  the  materials  used  is 
subjected  to  frequent  chemical  analyses,  so  that  no  marked  variation  in 
the  quality  of  the  milk-supply  can  exist  long  without  detection.  In  the 
home  modification  of  milk,  therefore,  the  physician  should  clearly  grasp 
the  conditions  under  which  the  composition  of  milk  and  creams  varies,  as 
described  in  the  previous  pages,  and  by  an  intelligent  observation  of  the 
facts  should  check  the  results  of  his  feeding. 

The  improper  combinations  which  are  often  given  to  infants  arise  from 
a  misconception  of  the  nutritive  demands  of  the  individual  child.  Too 
many  infants  are  fed  by  general  rules,  applying  to  the  average  healthy 
infants,  whereas  the  teaching  we  would  impress  upon  physicians  is  that 
each  child  has  its  own  idiosyncrasy  of  digestion,  and  the  general  principles 
outlined  must  be  used  in  adapting  the  milk  to  individual  requirements. 
We  repeatedly  see,  for  instance,  new-born  or  premature  infants  started 
upon  a  combination  calling  for  4  per  cent,  fat,  7  per  cent,  sugar,  and  1  per 
cent,  proteid,  whereas,  as  a  matter  of  fact,  a  milk  of  this  strength  may  not 
be  suited  to  a  given  infant  until  it  is  six  or  eight  weeks  of  age.    On  the  other 


FEEDING.  203 

hand,  an  infant  of  ten  months,  which  woula  ordinarily  receive  a  4  per 
cent,  fat,  7  per  cent,  sngar,  and  2.50  per  cent,  proteids,  and  a  cereal  de- 
coction in  place  of  the  boiled  water,  may,  owing  to  its  disturbed  diges- 
tion and  nutrition,  have  a  capacity  to  digest  a  milk  no  stronger  than  would 
be  given  to  a  new-born  infant,  such  as  a  2  per  cent,  fat,  5  per  cent,  sugar, 
and  0.50  per  cent,  proteids. 

In  hot  weather  one  also  labors  under  the  disadvantage  in  home  modi- 
fications of  handling  the  milk  under  conditions  which  favor  the  develop- 
ment of  bacterial  growth.  This  difficulty  can,  of  course,  often  be  overcome 
if  the  physician  appreciates  the  possible  danger  of  such  contamination  and 
insists  upon  the  proper  precautions  bemg  taken  as  regards  scrupulous 
cleanliness  of  vessels  and  hands,  and  the  utmost  care  in  keeping  the  milk 
thoroughly  iced. 

Much  has  been  written  of  the  idiosyncrasy  of  certain  infants  against 
cow's  milk.  It  is  impossible  to  deny  that  such  cases  exist,  but  the  more 
attention  one  pays  to  modification  of  milk  to  meet  the  especial  peculiarities 
of  digestion  in  different  babies,  the  more  skeptical  one  becomes  as  to  their 
occurrence,  especially  when  the  adaptation  of  the  percentages  of  the  fats, 
sugar  and  proteids  is  intelligently  directed  from  tlie  beginning  of  life.  The 
difficulties  in  feeding  met  Avith,  after  months  of  improper  modification,  are 
to  be  referred  to  the  chronic  disturbances  of  the  digestion  which  have  been 
allowed  to  develop,  and  not  to  the  existence  of  a  milk  idiosyncrasy. 

Peptonization  of  Milk. — Peptonized  milk  is  cow's  milk  with  its  pro- 
teids partially  or  entirely  predigested  by  means  of  the  extract  of  pancreas 
and  soda.  There  is  no  doubt  that  the  proteids  of  cow's  milk  are  at  times 
a  source  of  trouble  to  the  infant's  digestion,  and  that  under  certain  cir- 
cumstances they  can  with  great  benefit  be  treated  by  predigesting  them 
for  a  time,  and  allowing  a  stomach  which  otherwise  digests  well  to  rest 
and  recover  its  entire  digestive  power.  It  is  of  use  also  where  a  decided 
idiosyncrasy  of  the  individual  precludes  the  digestion  of  these  constituents 
of  the  milk.  In  many  cases  the  indigestion  is  attributed  to  a  lack  of 
power  to  digest  proteids  at  all,  while  in  fact  the  stomach  is  simply  rebel- 
ling against  an  amount  of  proteids  above  the  standard  percentage,  or 
against  some  other  constituent.  It  would  seem  that,  for  the  average  in- 
fant, this  predigestion  of  the  proteids  is  contrary  to  nature's  teaching. 
There  are  certain  natural  functions  which  should  be  allowed  to  act  as 
they  do  on  human  milk,  and  it  seems  irrational  and  contrary  to  the  laws 
of  physiology  not  to  encourage  all  the  functions  to  act  naturally,  instead 
of  forestalling  their  action  and  allowing  them  to  fall  into  disuse  and  thus 
to  be  weakened.  The  infant's  stomach  is  intended  to  digest  proteids,  and 
not  to  have  the  proteids  digested  for  it.  Clinically,  also,  the  use  of  pep- 
tonized milk  supports  this  view,  for,  so  far  as  we  know,  no  very  brilliant 
results  have  been  obtained  from  its  use,  except  when  the  infant's  digestion 
has  been  in  an  abnormal  condition  and  one  which  lias  called  for  some 
decided  relief  from  the  proteid  elements  of  milk.     Peptonized  whole  milk, 


204  PEDIATRICS. 

therefore,  as  a  food  for  young  infant-;  is  one  which  consists  of  too  large  an 
amount  of  digested  proteids,  too  little  sugar,  and  a  Aery  large  over  propor- 
tion of  mineral  matter.  Peptonization  of  modified  milk  should  only  be 
given  in  cases  in  Avhich  it  has  been  found  that  various  combinations  of  the 
fat  and  sugar  with  very  low  percentages  of  the  proteids  have  proved 
inefficient. 

The  teehnicjue  for  the  peptonization  of  whole  milk  is  as  follows  : 

In  a  clean  glass  jar  containing  4  ounces  of  cold  distilled  or  boiled 
water  dissolve  1  gramme  (15  grains)  of  bicarbonate  of  soda  and  0.25 
gramme  (5  grains)  of  pancreatine  (extractum  pancreatis),  to  which  add  12 
ounces  of  the  milk.  Set  tlie  jar  in  a  vessel  of  water  at  a  temperature  of 
41.6°  C.  (107°  F.)for  from  seven  to  ten  minutes,  or  longer,  according  to  the 
extent  to  which  it  is  desired  to  carry  the  peptonizing  process.  Cool 
immediately,  and  keep  on  ice  until  used. 

To  peptonize  modified  milk  an  amount  of  the  powders  should  be  used 
corresponding  to  the  percentage  of  the  proteids  in  the  mixture,  A  mixt- 
ure containing  2  per  cent,  of  proteid,  for  mstance,  would  recpire  only  half 
as  much  of  the  extract  of  pancreas  as  would  be  needed  for  whole  milk. 

Commercial  "  peptonizing  tubes  "  are  convenient  to  use.  If  the  milk 
is  to  be  given  by  mouth,  the  peptonizing  process  should  not  be  carried 
on  for  more  than  fifteen  or  twenty  minutes  at  the  most,  as  its  bitter  taste 
may  make  it  unpalatable.  The  peptonizing  process  can  be  checked  at  any 
time  by  cooling  and  icing  the  bottles,  or  the  ferment  may  be  destroyed  by 
heating  the  milk  to  68.3°  C.  (155°  F.).  For  rectal  enemata  the  peptonizing 
process  should  be  carried  on  for  at  least  one  hour. 

The  Use  of  Cereals  in  Percextage  Feeding. — When  a  physician  orders 
cereals  to  be  prepared  at  the  laboratory,  he  is  enabled  to  obtain  prepa- 
rations containing  exact  percentages  of  the  constituents  of  any  cereal 
food.  (See  page  216.) 

When  starch  is  prescribed  it  should  be  calculated  in  definite  per- 
centages, beginning  with  0.25  per  cent,  and  increasing  it  in  proportion  .to 
the  infant's  powers  of  digestion. 

This  brings  us  to  the  consideration  whether  starch  should  be  made  a 
part  of  an  infant's  food.  Physiologically,  we  know  that  during  the  first 
ten  or  twelve  months  of  life  the  function  of  converting  starch  into  sugar 
is  in  the  process  of  development.  It  is  true  that  a  partial  conversion  of 
the  starch  can  be  performed  at  quite  an  early  age,  and,  in  exceptional 
cases,  to  a  much  greater  extent  than  by  the  average  infant.  It  is  rational 
to  suppose  that  when  a  function  is  being  developed  it  should  not  be  taxed 
with  a  trial  of  the  use  which  will  later  be  demanded  of  it.  That  is,  a 
function  develops  more  perfectly  if  its  power  is  not  exerted  too  early. 
With  these  facts  before  us,  and  simply  recognizing  that  the  best  known 
food  for  ^.nfants,  woman's  milk,  does  not,  under  any  circumstances,  contain 
starch,  we  believe  that  starch  should  not  form  a  part  of  the  infant's  food 
in  the  early  months  of  the  first  year.  (See  page  177.) 


FEEBIXG.  205 

When,  in  the  eighth,  ninth  or  tenth  month,  it  is  deemed  best  to  give 
cereals,  it  is  desirable  not  to  give  immediately  a  high  percentage  of  starch 
in  the  mixture.  We  should  not  ignore  the  fact  tliat  the  various  cereals 
contain  fat  and  proteids  as  well  as  starch,  and  that  the  percentage  of 
sugar  in  the  mixture  will  be  raised  by  the  converted  starch.  A  gradual 
change  should  be  made  in  the  infant's  food  until  its  digestive  capabilities 
have  become  adapted  to  the  food  values  indicated  for  digestion  and 
nutrition  in  the  second  year,  such  as  are  represented  by  a  higher  rate  of 
fat,  sugar,  and  proteids.  It  is  Avell  in  the  second  year  to  use  an  undiluted 
milk,  preferably  from  Holstein  cows,  and  to  obtain  the  increased  sugar 
ratio  from  the  starch  given  plus  the  4.75  per  cent,  of  sugar  in  the  milk. 
Any  additional  sugar  that  may  be  needed  at  this  time  may  be  given  with 
the  food  in  the  form  of  cane-sugar,  rather  than  milk-sugar.  The  starch 
can  best  be  obtained  from  the  preparations  of  oats  and  barley,  as  described 
on  pages  168  and  184. 

The  Emulsion  in  Modified  Milk. — As  the  question  lias  arisen  in  the 
minds  of  some  physicians  as  to  whether  it  is  wise  to  use  a  centrifugal 
cream  in  making  a  modification,  the  objection  being  that  the  centrifuge 
destroys  the  emulsion,  the  following  photomicrograph  (Fig.  47)  of  a  drop 
of  unmodified  cow's  milk  is  interesting  to  study.  The  analysis  of  this 
especial  milk  was  as  follows  : 

Cmiys  Milk. 

Fat 4.04 

Sugar 4.55 

Proteids 4.15 

Mineral  matter ' 0. 71 

Total  solids ■ 13.45 

Water - 86.55 

100.00 

Fig.  48  represents  a  drop  of  cow's  milk  modified  to  correspond  to  the 
same  analysis  as  in  Fig.  47  ;  and  in  examining  the  two  drops  it  will  be 
seen  that  the  emulsion  in  the  modified  drop  is  quite  as  fine  as,  if  not 
finer  than,  that  in  the  unmodified. 

Fig.  49  represents  a  drop  of  human  milk,  and  Fig.  50  a  drop  of  cow's 
milk,  modified  so  as  to  correspond  to  the  percentages  of  the  human  milk, 
which  were  as  follows  : 

Human  Milk. 

Fat....; 2.67 

Sugar 6.37 

Proteids 2.69 

Mineral  matter 0.15 

Total  solids 11. 88 

Water 88.12 

100.00 


206 


PEDIATRICS. 


Fig.  47. 


Unmodified  cow's  milk. 


Fig.  48. 


Cow's  milk  sejiarated  and  recomf)osed. 


FEEDING. 


207 


Fig.  49. 


Human  milk. 


Fig.  50. 


ilodified  cow's  milk. 


208  PEDIATRICS. 

The  emulsion  in  tliese  two  drops  of  milk  seems  to  correspond  very 
closely,  and  certainly  does  not  warrant  the  assumption  that  the  emulsion 
has  been  seriously  interfered  with  by  separation  and  recomposition. 

It  has  been  noticed  that  in  certain  instances  when  a  cream  mixture  is 
subjected  to  the  jar  dependent  upon  transportation  and  delivery  for  any 
considerable  distance,  a  portion  of  the  fat  has  a  tendency  to  collect  on  the 
surface  of  the  milk  in  globules.  Experiments  made  by  White  and  Ladd 
under  our  direction  have  shown  that  transportation  alone  was  not  suffi- 
cient to  produce  this  disturbance  in  the  emulsion,  and  that  it  did  not 
depend  alone  upon  the  use  of  centrifugal  cream.  Centrifugal  and  gravity 
cream  mixtures,  after  eight  to  eleven  hours  of  transportation  on  several 
successive  days  at  a  temperature  such  as  prevails  in  average  October 
weather,  showed  essentially  the  same  macroscopic  and  microscopic  ap- 
pearances, and  their  emulsions  were  hardly  to  be  distinguished  from  that 
of  whole  milk.  Moreover,  it  was  found  possible  to  produce  these  globules 
in  a  modified  milk  by  placing  the  bottles  in  a  box,  the  interior  of  which 
was  kept  w^arm  during  transportation  by  means  of  a  vessel  containing  hot 
water,  which  was  renewed  at  intervals.  Our  opinion,  based  on  the  result 
of  these  experiments,  is  that  the  globules  are  produced  by  a  combination 
of  motion  of  transit  with  boat,  such  as  prevails  in  summer;  and  we  have 
not  found  the  nutritive  value  of  the  milk  to  be  at  all  interfered  with  in  the 
exceptional  cases  in  which  the  change  occurs. 

THE  MILK-LABORATORY.— In  this  busy  age  of  scientific  rational 
medicine  physicians  all  over  the  world  demand,  first,  means  of  saving 
time,,  and  second,  exact  methods  of  work,  which  in  themselves  soon 
become  time-savers.  In  every  branch  of  our  art  the  tendency  is  growing 
year  by  year  to  systematize  the  detailed  and  laborious  work  of  the  indi- 
vidual for  the  common  practical  use  of  the  profession  at  large.  The 
subject  of  substitute  feeding  should  be  reduced  to  a  more  exact  system, 
and  an  effort  should  be  made  to  rescue  this  important  branch  of  pediatrics 
from  the  pretensions  of  the  owners  of  proprietary  foods  and  the  hands  of 
ignorant  nurses.  With  this  end  in  view,  we  have  given  our  professional 
assistance  to  the  establishment  of  a  system  of  milk-laboratories  where  the 
materials  used  shall  be  clean,  sterile,  and  exact  in  their  percentages. 
These  laboratories  have  been  placed  under  the  control  of  educated,  intelli- 
gent men  in  whom  we  have  the  same  confidence  that  we  have  conceded 
to  the  pharmacist,  and  we  can  write  directions  for  infants'  foods  and  send 
them  to  these  laboratories  just  as,  in  the  treatment  of  disease,  we  write 
our  prescriptions  for  the  division  of  one  drug  or  the  combination  of 
several.  As  the  pharmacist  has  nothing  to  do  with  the  various  methods 
of  treating  disease,  so  the  milk-modifier  is  simply  required  to  carry  out  the 
directions  and  ideas  of  the  physician,  and  the  laboratory  assumes  no 
responsibility  as  to  the  success  or  failure  of  the  food.  The  result  attained 
depends  wholly  upon  the  physician's  intelligence  in  the  use  of  this  instru- 
ment of  feeding,  and  upon  the  condition  of  the  infant  for  whom  the  food 


FEEDING.  209 

is  ordered.  No  special  school  of  medicine  need  be  represented.  No 
special  method  of  feeding  need  be  midertaken.  An  opportunity  has,  how- 
ever, for  the  first  time  in  the  history  of  medicine,  been  presented  for  the 
physician  to  carry  out  his  own  methods,  and  these  methods  for  the  first 
time  to  be  judged  on  a  fair  basis.  In  this  way  only  can  each  clinical 
observer,  when  lacking  in  success,  be  sure  that  it  is  the  fault  of  the  food 
he  is  giving,  and  not  because  the  food  has  varied  from  what  he  supposed 
he  had  ordered,  owing  to  errors  in  calculation  and  modification. 

The  means  for  prescribing  a  diversity  in  the  elements  of  milk,  accord- 
ing to  the  idiosyncrasy  of  the  digestion  we  are  dealing  with,  is  supplied  by 
a  milk-laboratory  equipped  with  special  machinery  and  controlled  by 
educated  milk-modifiers.  Purity  of  the  original  material  is  the  first  object 
to  be  attained.  This  material,  milk,  should  be  obtained  from  cows  bred, 
fed,  and  cared  for  in  the  manner  described,  and,  in  order  to  insure 
absolute  uniformity  in  the  methods,  untiring  vigilance  must  be  used  in  the 
supervision  of  the  farm,  cows,  and  milk-house,  and  in  the  transportation 
of  the  milk  from  the  farm  to  the  laboratory.  It  is  also  necessary  that  the 
cows  should  be  under  the  medical  supervision  of  a  skilled  veterinary  sur- 
geon. These  are  all  questions  which  to  our  mind  have  been  definitely 
decided,  but  which  now  need  time  and  attention  devoted  to  them  to  insure 
their  being  systematically  carried  out.  As  in  all  other  advances  which  are 
made  in  practical  medicine,  so  also  in  this  one  it  is  well  to  adopt  at  once  a 
high  standard  of  work  and  to  demand  everything  that  can  in  any  way 
tend  to  perfection.  We  may  not  always  be  successful  in  carrying  out  all 
the  details,  but,  until  we  are,  perfection  will  not  be  reached.  It  must, 
then,  be  borne  in  mind  and  understood  that  each  link  of  that  chain  is  of 
vital  importance,  because,  if  broken,  the  value  of  the  whole  chain  may  be 
lost.  One  end  of  this  chain  is  at  the  milk-farm.  Starting  in  the  stall  of  the 
cow  it  passes  on  to  the  milk-house,  from  the  milk-house  to  the  milk- 
laboratory,  and  from  the  laboratory  it  should  be  carried  unbroken  and 
intact  to  the  infant  consumer. 

As  milk-laboratories  are  now  so  well  known,  and  have  for  some  years 
been  established  all  over  the  United  States  and  in  Canada  and  London, 
they  need  not  be  described  in  great  detail. 

A  milk-laboratory  should  be  a  place  to  which  the  milk  should  be  de- 
livered from  such  farms  and  under  such  precautions  as  have  already  been 
described  ;  it  should  be  m  a  central  localuy,  accessible  to  as  many  people 
as  possible,  and  used  exclusively  to  prepare  from  the  prescriptions  of 
physicians  alone  any  modification  of  milk  which  may  be  called  for. 

As  milk  is  one  of  the  best  means  for  the  cultivation  of  bacteria,  the 
laboratory  should  be  situated  in  a  healthy  locality  It  should  be  as  free  as 
possible  from  contaminating  influences,  should  be  kept  absolutely  clean, 
and  every  aseptic  precaution  against  the  harboring  or  development  of 
pathogenic  organisms  should  be  taken.  To  insure  perfect  work  the  great- 
est vigilance  is  needed  in  every  department  of  such  a  laboratory. 

14 


210  PEDIATRICS. 

From  tlie  moment  that  the  milk  is  deUvered  from  the  farm  at  a  tem- 
perature of  about  4.4°  C.  (40°  F.)  it  should  be  watched  over  and  cared 
for  with  scientific  accuracy  during  the  whole  process  of  the  modification 
which  it  undergoes  in  the  laboratory.  The  milk-rooms  should  be  cool 
and  free  from  dust,  and  isolated,  so  far  as  possible,  from  other  parts  of  the 
laboratory. 

There  should  also  be  an  entirely  separate  room  where  the  returned 
packages  and  all  articles  received  from  the  homes  of  the  consumer  should 
be  directly  brought  from  the  street  or  wagons,  and  where  these  articles 
can  be  immediately  sterilized  in  apparatus  reserved  for  this  purpose. 

The  modifying  materials  used  in  the  laboratory  should  be  carefully 
kept  for  use  in  glass  vessels,  and  at  a  temperature  of  about  4.4°  C.  (40° 
F.),  to  prevent  the  growth  of  bacteria.  The  reason  for  this  is  that  milk 
modified  from  materials  free  from  bacteria  is  not  only  better  for  the  infanl 
than  milk  in  which  the  bacteria  have  been  destroyed  by  heat,  but  thai 
tliere  are  certain  toxines  which  cannot  be  destroyed  by  heat,  and  by  their 
virulence  may  cause  serious  disturbance  even  after  the  most  thorough 
sterilization  has  been  carried  out.  In  a  carefully  guarded  milk-supply  also 
it  is  seldom  necessary  to  ever  pasteurize  a  milk  which  is  sent  out  from  a 
well-equipped  laboratory,  except  in  very  hot  weather. 

A  special  room  should  be  provided  for  the  milk-modifiers  who  are  to 
put  up  the  mixtures  required  by  each  prescription.  There  should  either 
be  a  room  in  the  laboratory  where  the  milk  is  separated  by  means  of  ma- 
chinery and  where  it  can  be  tested  and  steamed,  or  this  can  be  done  in 
the  milk-roorn  at  the  farm.  The  office  at  the  laboratory  should  be  entirely 
separate  from  these  work-rooms,  so  that  customers  coming  to  leave  their 
orders  should  not  go  near  the  materials  used  for  modification  and  thus 
possibly  contaminate  them.  All  odors  should  be  excluded  from  the  work- 
rooms, as  they  are  absorbed  by  milk  very  quickly.  It  is  hardly  necessary 
to  say  that  the  employees  of  a  laboratory,  whether  they  be  in  the  office 
or  in  the  work-rooms,  should  be  intelligent  and  interested  in  their  work, 
and  that  the  modifying  clerks  should  be  especially  instructed  in  the  neces- 
sity of  absolute  cleanliness,  should  be  made  to  understand  the  dangers  of 
sepsis  and  the  importance  of  asepsis,  together  with  a  practical  knowledge 
of  how  to  guard  against  and  exclude  pathogenic  organisms. 

MiLK-RooM. — The  milk  should  be  aerated  and  cooled  to  about  6.66° 
C.  (44°  F.)  at  the  farm,  then  packed  in  ice  in  such  a  way  as  to  maintain 
its  temperature  during  transportation  below  7.22°  C.  (45°  F.),  and  deliv- 
ered to  the  milk-room  within  a  few  hours  of  the  time  of  milkins'. 

This  milk,  as  a  result  of  the  especial  manner  in  which  the  cows  have 
been  fed  and  cared  for  and  the  selection  of  them  according  to  the  proper 
breed,  may  be  said  to  have  an  almost  uniform  percentage  of  its  elements. 
Even  at  those  times  of  the  year  when  the  percentages  of  the  different  ele- 
ments of  milk  commonly  vary  from  changes  in  the  pasturage  and  in  the 
habits  and  surroundings  of  the  animals,  the  milk  of  these  cows,  which 


FEEDING. 


211 


Fig.  51. 


have  their  food  supplied  to  them  in  stated  rations  at  one  time  of  the 
year  as  well  as  another,  is  not  subject  to  the  elemental  variations  which 
occur  in  the  milk  of  ordinary  cows. 

Separating-Room. — The  milk  can  be  separated  either  at  the  farm  or 
in  the  laboratory  in  a  room  arranged  and  cared  for  in  very  much  the 
same  way  as  the  milk-house  at  the  farm.  The  walls  are  of  white  tile,  or 
cement,  and  the  ceilings  are  of  material  which  can  be  washed  and 
scrubbed.  The  floor  is  of  asphalt,  impenetrable  to  water,  and  is  kept 
thoroughly  moistened  and  free  from  every  kind  of  dirt  and  dust. 

Ventilator. — In  addition  to  the  other  precautions  against  pathogenic 
germs,  the  air  of  the  separating-room  is  kept  fresh  and  pure  by  means  of 
a  ventilator.  This  consists  of  a  large  steel  fan,  which  revolves  at  the  rate 
oftwo  thousand  times  a  minute,  and  by  the  force 
of  its  current  carries  away  any  flies  or  particles 
of  dust  which  may  come  within  its  reach.  The 
air  which  comes  into  the  separating-room,  as 
well  as  into  the  milk-room  and  modifying-room, 
should  be  washed  with  sterile  water. 

Separator.  —  The  centrifugal  sejxtrator  re- 
volves from  six  to  nine  thousand  times  in  a 
minute,  and  works  with  such  searching  effect  on 
the  milk  that  only  a  small  percentage  (0.05)  of 
fat  remains  in  the  separated  milk. 

The  utility  of  the  separator,  however,  does  not 
consist  wholly  in  its  absolute  withdrawal  of  the  fat 
from  the  milk  and  in  providing  cream  as  fresh  as 
to  time  as  is  the  separated  whole  milk :  by  its 
great  centrifugal  force  it  separates  from  the  cream 
and  the  separated  milk  any  dirt  or  foreign  matter 
of  any  kind  which  necessarily  gets  into  every  milk, 
and  thus  provides  a  practically  clean  milk,  an  im- 
portant result  from  a  bacteriological  point  of  view. 

Still. — A  still  for  freshly  preparing  each  day  distilled  water  is  part  of 
the  laboratory  equipment. 

MoDiFYiNG-RooM. — In  the  modifying-room  the  milk  is  tested  and  the 
modification  of  the  milk  is  completed. 

Babcock  Pat-Tester. — To  be  doubly  sure  that  the  chemistry  of  the 
milk  is  what  we  suppose  it  to  be  from  the  uniform  nature  of  the  primal 
milk-supply,  we  take  advantage  of  the  knowledge  which  we  have  concern- 
ing the  changes  most  likely  to  take  place  in  certain  elements  of  the  milk. 

The  percentage  of  the  proteids,  of  the  sugar,  and  of  the  mineral  mat- 
ter in  the  milk  of  a  herd  of  this  kind,  where  uniformity  in  the  feeding  is 
the  rule,  is  not  apt  to  be  appreciably  affected.  But  the  percentage  of  the 
fat  in  individual  cows  differs  from  day  to  day,  and  thus  slightly  affects  the 
percentage  of  the  fat  in  the  milk  of  the  herd. 


Centrifugal  separator. 


212  PEDIATHK'S. 

The  fat,  then,  being  the  element  by  which  Ave  know  whether  each 
milking  gives  a  uniform  product,  we  test  this  element  by  means  of  what  is 
called  the  "  Babcock  Fat-Tester."  Fig.  52  shows  the  Babcock  machine. 
To  determine  the  percentage  of  fat,  test-bottles  containing  the  acidified 
milk  are  placed  in  a  centrifugal  machine,  by  the  rapid  revolution  of 
which  the  fat  is  made  to  separate  quickly  and  completely.     The  milk  is 

Fig.  52. 


Babcock  fat-tester. 


acidified  in  order  that  the  proteids,  casein  and  fibrin,  may  be  changed  to 
soluble  acid  albumins,  which  offer  less  resistance  to  the  rising  and  aggre- 
gation of  the  fat-globules. 

Approximately  equal  volumes  of  milk  and  commercial  sulphuric  acid 
of  1.82  specific  gravity  are  mixed  in  a  test-bottle  w4th  a  long  graduated 
neck.  A  pipette,  delivering  about  17.5  c.c.  of  milk,  and  a  measuring 
cylinder  for  the  acid,  are  used.  The  bottles  are  whirled  for  several  min- 
utes at  a  temperature  of  93°  C.  (200°  F.)  in  a  horizontal  wheel  making 
Trbm.  nine  to  eleven  hundred  revolutions  per  minute.  For  an  accurate  test 
there  should  be  a  pressure  of  80.65  pounds  on  each  bottle.  To  obtain 
this  with  a  wheel  of  10-inch  diameter,  1074  revolutions  per  mmute  are 
required  ;  with  a  wheel  of  12-inch  diameter,  980  revolutions.  This  wheel  is 
surrounded  by  a  copper  jacket,  Avhich  may  be  filled  with  hot  water  for 
heating  during  the  test.  The  separation  of  fat  by  gravity  alone  is  not 
complete  even  when  the  bottles  are  left  standing  for  several  hours.  By 
the  centrifuge,  however,  a  perfect  separation  is  accomplished  in  a  few 
minutes.  If  whirled  at  once,  no  heat  need  be  applied,  as  that  caused  by 
the  strong  acid  and  milk  is  sufficient.  After  whirling,  the  bottles  are 
filled  to  the  neck  with  hot  water,  returned  to  the  machine,  and  whirled 
for  one  or  two  minutes  longer,  after  which  they  are  filled  with  hot  water 
to  about  the  seven  per  cent,  mark,  and  the  machine  is  again  turned  for  a 
short  time,  the  temperature  being  kept  up  by  means  of  a  lamp  or  by 


FEEDING. 


213 


filling  the  jacket  with  hot  water.  The  fat  separates  and  its  percentage  is 
noted  while  still  liquid,  preferably  at  about  65°  C.  (150°  F.),  the  reading 
giving  the  percentage  of  fat  directly  without  calculation  and  being  easily 
taken  to  0.1  per  cent. 

This  daily  testing  of  the  fat  enables  the  mochfier  to  preserve  the  accu- 
racy of  his  material,  and  to  correct  any  variation  in  the  percentage  of  the 
cream  as  it  comes  from  the  separator. 

Knowing  the  exact  percentages  contained  in  the  cream  and  milk,  the 
office  clerk  can,  by  a  simple  mathematical  formula,  give  the  required 
directions  on  the  modifying'  clerk's  formula  for  obtaining  whatever  per- 
centages of  the  other  elements  the  physician  may  call  for. 

Apparatus  for  the  Transportation  of  Modified  Milk. — Fig.  53  repre- 
sents the  various  forms  of  apparatus  which  are  provided  for  feeding  the 

i'lfant  in  its  home. 

Fig.  53. 


I'i  the  left  of  the  picture  is  a  basket  holding  eight  tubes  of  a  capacity  ui  six  uiinecs  each.  In  front  of 
this  basket  is  a  four-ounce  tube  in  a  wire  stand.  In  the  middle  of  the  picture  is  a  tin  apparatus  for 
warming  the  milk  at  the  time  of  feeding.  An  alcohol  lamp  is  shown  beneath  the  warmer,  and  a  tube 
of  milk  and  a  thermometer  for  testing  the  temperature  of  the  milk  are  in  the  tin  warmer.  Next  to  and 
to  the  right  of  the  tin  warmer  is  a  tube  with  a  capacity  of  eight  ounces.  It  is  enclosed  in  a  white  worsted 
cozy,  has  the  rubber  nipple  in  place,  and  is  supp<5rted  in  a  wire  stand.  In  the  right  of  the  picture  is  a 
basket  containing  six  tubes  with  a  capacity  of  eight  ounces  each.  In  front  of  this  basket  are  an  eight- 
ounce  tube  and  a  four  ounce  tnbe.  The  bottles  are  now  stoppered  with  sterilized  aluminum  caps, 
instead  of  with  plugs  of  cotton. 

This  apparatus  is  very  simple  and  practical  for  transportation.  A 
wicker  basket,  divided  into  a  number  of  compartments  corresponding  to 
the  number  of  feedings  which  are  to  be  sent  to  the  infant,  has  been  found 
to  be  the  most  practical.  These  baskets  with  their  tubes  can  be  placed 
directly  in  the  sterilizer,  and  are  not  harmed  by  the  heat  to  which  it  is 
necessary  to  expose  the  food. 

This  tin  receptacle  can  be  placed  above  an  alcohol  lamp  ;  the  water  in 
it  is  to  be  on  a  level  with  the  height  of  the  milk  which  is  contained  in  the 
tube,  and  the  tube  is  submerged  in  the  water.  It  has  been  found  neces- 
sary to  take  the  temperature  of  the  food  by  means  of  a  thermometer 
placed  directly  in  the  tube.     No  rule  can  be  laid  down  by  which  the  tem- 


214 


PEDIATRICS. 


peraUire  of  the  waler-baLli  determines  that  of  tlio  iiiil]<,  unless  the  tubes 
are  of  uniform  thickness  and  the  millv  uniform  in  (|uantity  and  tempera- 
ture when  placed  in  the  batli.  The  thermometer  must  be  washed  in 
sterilized  water  with  the  greatest  care,  both  before  and  after  it  is  used. 
The  food  when  given  to  the  infant  should  have  a  temperature  of  from 
36.6°  to  37.7°  C.  (98°  to  100°  F.). 

As  in  direct  feeding  from  the  breast  the  food  which  the  infant  receives 
has  the  same  temperature  at  the  end  of  the  feeding  as  at  the  beginning, 
we  should  copy  this  provision  of  nature  and  not  allo^v  tlio  temperature 
of  the  food  to  vary  during  the  tune  it  is  being  taken.  To  accomplish  this 
end,  a  white  worsted  cozy  can  be  used.  The  cozy  is  warmed  at  the  same 
time  that  the  milk  is  being  heated,  and  the  tube  when  placed  in  it  is  pre- 
vented from  cooling.  Thus  the  infant  receives  a  food  of  unvarying  tem- 
perature throughout  the  whole  of  the  feeding. 

Fig.  54  represents  an  ice-box  which  can  be  used  in  hot  weather,  and 
lias  proved  to  be  of  great  practiral  utility.     It  admirably  serves  the  pur- 


FiG.  ,'i4. 


Ics-Ikjx,  holding  twelve  tubes.     Receptacle  for  ice  in  centre  of  txjx.     Laboi-aiory  iin-scriiition-lilank  in 
front  of  box,  and  packing  pay^er  under  end  of  open  lid. 


poses  of  an  express  box  and  of  a  home  refrigerator.  The  ice  is  packed  in 
a  metal  compartment  in  the  middle  of  the  box,  and  the  tubes  are  placed, 
each  in  its  owm  compartment,  around  the  sides  of  tlie  ice-receptacle. 

Materials  for  the  !Modificatiox  of  Milk. — The  materials  for  the  modi^ 
fication  of  milk  at  the  laboratories  consist  of  32  per  cent,  cream,  fat-free 
milk,  lime-water.  20  per  cent,  milk-sugar  solution,  distilled  water,  whey, 
and  freshly-prepared  stock  decoctions  of  either  barley,  oats,  or  rice,  made 
of  such  a  strength  that  they  contain  3.50  per  cent,  of  starch.  Unless  other- 
wise ordered  the  modifications  are  made  from  these  materials. 


FEEDING.  215 

By  calculation  also  a  whole  milk  can  be  used  in  place  of  the  separated 
milk,  and  a  gravity  cream  in  place  of  a  separated  cream,  if  a  few  hours' 
notice  is  given  by  the  physician  who  is  prescribing  the  mixture.  It  is  well 
that  this  latter  statement  should  be  noted,  as  physicians  often  think  that 
only  separated  milk  and  cream  are  used  at  the  laboratories,  and  that  the 
food  is  always  sterilized  or  is  always  made  alkaline  with  lime-water.  This 
is  not  the  case,  and  it  should  be  thoroughly  understood  that  the  laboratories 
are  ready  to  provide  whatever  the  physician  orders,  and  in  whatever  way  he 
orders,  and  that  they  are  not  allowed  to  do  anything  else,  either  to  prescribe, 
to  change  the  prescription,  or  to  sell  a  modified  milk  preparation  without  a 
physician's  prescription, —  that  is,  the  laboratory  is  merely  an  instrument  in 
the  hands  of  the  physician,  and  is  in  no  way  responsible  for  the  results  ob- 
tained from  the  feeding,  except  in  so  far  as  freshness  of  material  and  exact- 
ness of  combination  is  concerned.  The  physician,  on  the  contrary,  can  order 
his  prescriptions  to  be  delivered  unhealed  or  at  any  temperature,  whether  it 
be  68.3°  C.  (155°  F.),  75°  C.  (167°  F.),  or  100°  C.  (212°  F.) ;  alkaline  or  not, 
as  he  pleases,  and  if  alkaline,  made  so  in  any  way  he  prefers  to  order,  such 
as  by  lime-water  or  bicarbonate  of  soda  ;  his  fat  percentages  can  be  given 
him  with  gravity  cream  if  he  prefers  it  to  separated  cream,  and  his  proteids 
with  whole  milk  instead  of  separated  milk ;  also  his  sugar  can  be  cane- 
sugar  if  he  prefers  it  to  milk-sugar. 

The  physician,  however,  should  appreciate  that  separated  milk  con- 
tains far  less  dirt  and  much  fewer  bacteria  than  whole  milk,  and  that 
using  gravity  cream  means  a  six  or  eight  hours'  older  cream,  and  necessa- 
rily more  bacteria  than  a  quickly  separated  cream,  which  gives  us  as  fresh 
a  material  for  modification  as  the  milk.  We  personally  have  never  been 
able  to  satisfy  ourselves  that  the  emulsion  of  the  fat  was  in  any  way  dis- 
turbed by  the  separator,  and  our  clinical  experience,  which  has  been  large 
with  both  separated  and  unseparated  milk  and  cream,  has  never  shown 
that  any  harm  came  from  using  the  former. 

With  these  modifying  materials  the  modifying  clerks  combine  each 
infant's  food  according  to  the  prescription  before  them,  and  pour  it  into 
the  glass  tubes  from  which  the  infant  is  to  nurse.  These  tubes,  which 
have  been  especially  devised  as  the  most  practical  for  general  use,  are 
adapted  both  for  transportation  and  for  use  as  nursing-bottles,  and  are 
easily  cleansed. 

There  are  two  sets  of  clerks.  One  set  is  engaged  in  modifying  the 
milk  according  to  the  prescriptions.  As  soon  as  the  tubes  are  filled  by 
the  modifying  clerks  they  are  passed  on  to  the  stoppling  clerks,  who  im- 
mediately seal  them  with  sterilized  aluminum  caps,  and  place  them  in 
baskets,  the  compartments  of  which  are  adapted  to  the  number  of  feedings 
ordered  for  the  special  infant.  The  tubes  are  kept  on  tube-racks  within 
easy  reach  of  the  modifying  clerks.  Each  basket  has  its  own  label 
attached  to  it,  with  the  address  of  the  person  to  whom  it  is  to  be  sent. 
The  rule  of  absolute  cleanliness  is  carried  out  in  every  possible  detail, 


216  PEDIATRICS. 

from  the  table  on  wliiili  tlie  materials  are  combined  to  tlie  dress  and 
hands  of  the  clerks. 

The  milk  is  tlnis  separated  and  recombined  according  to  the  prescrip- 
tions, stoppled,  and  placed  in  their  respective  baskets  for  transportation. 

Limitations  of  Starch  Percentages. — Instead  of  writing  for  a  certain 
number  of  ounces  of  barley-water  or  barley  jelly,  we  can,  by  a  recent 
development  of  laboratory  facilities,  write  for  percentages  of  starch,  as  we 
would  for  those  of  fats,  sugar  or'  proteids.  High  percentages  of  fats  and 
proteids  require  so  many  ounces  of  milk  and  cream  that  the  number  of 
ounces  of  diluent  grows  progressively  less  as  the  composition  of  the  food 
approaches  that  of  whole  milk.  There  are,  therefore,  limitations  to  the 
starch  percentages  which  are  possible,  owing  to  the  limitations  of  the 
diluent.  The  thickest  practicable  cereal  jelly,  which  is  now  used  as  the 
basis  for  obtaining  starch  percentages,  contains  3.5  per  cent,  of  starch. 
Thicker  solutions  cannot  be  satisfactorily  strained.  The  possibilities  of 
combination  are  seen  in  the  following  table  : 

TABLE  47 

Practical  Limits  of  Cereal  Mixtures  in  Laboratory  IModitications. 

Any  percentage  of  fat  from  1  to  4  with 
Any  percentage  of  sugar  from  4  to  7  Avith 
Any  percentage  of  proteids  from  0.25  to  2.00 

may  be  prescribed  with 

Starch 0.25  per  cent. 

Starch 0.50  per  cent. 

Starch 0.75  per  cent. 

Starch 1 .00  per  cent. 

Starch 1.25  per  cent. 

If  the  proteid  is  2.25  %  the  starch  cannot  exceed 1.05  % 

If  the  proteid  is  2.50  %  the  starch  cannot  exceed 0.83  % 

If  the  proteid  is  3.00  ^  the  starch  cannot  exceed 0.30  % 

If  it  is  wished  to  calculate  how  many  ounces  of  the  3.50  per  cent. 
^ — STDlution  is  necessary  to  obtain  a  given  percentage  of  starch,  one  may  use 
the  following  formula  :     (For  analyses  of  cereals  see  pages  168  and  184.) 

Starch  ^  desired  X  number  of  ounces  of  mixture. 

No.    OF   Ounces   of   Cereal  = 

3. 50 

Modified  Milk  by  the  Quart. — Recently  there  has  been  introduced  a 
method  by  which  patients  may  buy  the  milk  by  the  quart,  modified  to 
meet  any  requirement.  The  object  of  this  is  to  bring  the  cost  of  the  milk 
within  the  means  of  all  except  the  very  poor.  Modified  milk  by  the  quart 
is  prepared  from  the  same  materials  and  with  the  same  care  as  that  put  up 
in  separate  tubes.  It  need  only  be  divided  at  home  into  as  many  tubes 
and  ounces  as  prescribed  by  the  physician,  thus  saving  time  and  labor,  and 
the  dangers  of  inaccuracy  and  contamination  which  home  modification 
may  involve.     After  the  milk  has  been  put  into  the  tubes  at  home,  it  must 


FEEDING.  217 

then  be  pasteurized,  if  the  iDhysiciaii  so  desires,  as  the  pasteurization  of 
milk  in  quart  jars  is  not  a  practicable  procedure  and  is  not  carried  out  at 
the  laboratory. 

Sterilization  of  the  Milk. — The  sterilizer  is  so  arranged  that  the  steam 
which  passes  througii  it  can  be  regulated  so  as  to  produce  any  degree  of 
heat  required  up  to  100°  C.  (212°  F.).  This  is  accomplished  by  an  auto- 
matic regulator  attached  to  the  steam-pipe. 

The  question  whether  milk  should  be  boiled  or  steamed  is  one  which 
is  not  of  much  significance,  and  can  be  settled  according  to  the  fancy  of  the 
individual  practitioner,  a  greater  or  less  destruction  of  the  bacteria  con- 
tained in  the  milk  taking  place  according  to  the  degree  of  heat  to  which  it 
is  submitted.  The  effect  of  different  degrees  of  heat  upon  milk  has  been 
described  on  page  175. 

After  the  food  has  been  heated,  the  baskets  are  taken  out  of  the 
sterilizer  and  placed  in  the  cooling-tank,  where  the  temperature  of  the 
food  is  reduced  to  13.3°  C.  (38°  F.).  The  baskets  are  then  placed  in  a 
refrigerator  until  the  time  of  delivery  and  are  then  conveyed  to  their 
various  destinations. 

When  the  baskets  are  delivered  at  the  homes  of  the  consumers,  the 
baskets  and  tubes  of  the  previous  day  are  returned  to  the  laboratory. 
When  they  reach  the  laboratory  they  are  taken  directly  from  the  street  to 
a  steam  sterilizer,  where  they  are  sterilized  at  a  high  temperature  and  the 
bottles  are  then  sent  to  the  wash-room,  which  is  entirely  shut  off  from  the 
rest  of  the  laboratory.  After  they  have  been  thoroughly  washed  they  are 
again  sterilized  and  placed  bottom  end  up  in  the  baskets  and  are  ready  to 
be  used  again. 

The  milk  from  the  farms  connected  with  the  laboratory  has  proved 
to  be  comparatively  free  from  bacteria,  and  in  most  instances  it  is  un- 
necessary to  destroy  the  few  bacteria  which  exist  in  it ;  and  as  it  is  not 
harmful  to  the  infant,  it  need  not  be  exposed  to  heat.  When,  however, 
the  milk  has  to  be  transported  a  long  distance,  or  when  the  infant  has 
a  delicate  digestion  or  is  sick,  it  is  often  better  to  heat  the  milk  to  68.3° 
C.  (155°  F.).  This  temperature  is  sufficient  to  kill  those  developed  bac- 
teria which  would  be  of  any  harm  to  the  digestion  of  the  infant,  and  at 
the  same  time  is  below  72°  C.  (161.6°  F.),  the  point  at  which  coagulation 
of  the  proteids  is  supposed  to  take  place.  We  thus  obtain  a  practically 
pure  fresh  milk,  uncooked  and  sterile.  We  therefore  write  in  our  pre- 
scription 68.3°  C.  (155°  F.).  If  the  milk  is  to  be  sent  an  unusually  long 
distance,  if  the  weather  is  hot,  or  if  the  milk-supply  has  to  last  more  than 
twenty-four  hours,  a  higher  degree  of  heating  can  be  used,  according  to 
the  wish  of  the  prescriber.  Thus,  100°  C.  (212°  F.)  is  a  temperature 
used  for  these  purposes  at  the  laboratory.  When,  again,  we  wish  the 
milk  to  be  absolutely  sterilized,  as  may  be  the  case  when  we  are  preparing 
it  for  an  ocean  voyage  or  for  a  trip  across  the  continent,  not  only  a  high 
degree  of  heat,  100°  C.  (212°  F.),  but  two  or  three  heatings,  with  intervals 


218 


PEDIATRIC 


of  tweiily-four  hours,  are  necessary  for  this  complele  sterilizalicjii,  and 
this  can  be  called  for  in  our  prescription.  The  length  of  tune  during  which 
the  milk  should  be  heated,  as  a  rule,  can  be  left  to  the  judgment  of  the 
superintendent.  Ten  minutes  is  often  sufficient  to  kill  the  developed  bac- 
teria and  to  make  this  especially  protected  milk  practically  sterile.  Expe- 
rience, however,  has  proved  that  during  transportation  the  milk  is  often 
exposed  to  temperatures  conducive  to  the  further  development  of  bac- 
teria, and  that  practically  the  bacteriological  results  which  we  obtain  in 
the  laboratory  do  not  entirely  hold  when  the  milk  is  exposed  to  these 
varied  conditions  of  transit.  As  a  rule,  therefore,  from  twenty  to  thirty 
minutes  is  the  proper  time  to  heat  mixtures  of  mochfied  milk  sent  from 
the  laboratory. 

If  milk  containing  15  to  25  per  cent,  of  lime-water  is  heated  to  100°  C. 
(212°  F.)  a  reaction  takes  place  between  the  lime  and  the  sugar,  w'hich 
turns  the  mixture  brown  and  alters  its  taste.  It  is  better  in  such  cases  to 
heat  the  milk  first  and  then  add  the  lime-water. 

In  this  way,  always  guarding  against  possible  infection  of  all  kinds,  the 
laboratory  enables  us  to  make  use  of  the  chemical  and  bacteriological 
knowledge  which  we  have  accjuired  in  connection  with  the  feeding  of 
infants,  and  fulfils  the  requirements  of  that  system  of  substitute  feeding 
which  up  to  the  present  time  has  proved  to  be  the  best. 

The  following  is  a  sample  prescription,  in  which  the  physician  writes 
for  a  total  proteid  without  reference  to  the  relative  proportion  of  casein- 
ogen  and  lactalbumin  : 


R 


Fat 

Milk-sugar 

Total  proteid 

(a)  AVhey-proteids . 

(6 )  Caseinogen  . . . . 

Starch 


Ordered  for 
Date 


Per  Cent. 


Number  of  feedings 7 

Amount  of  each  feeding.  .  135  c.c. (f  54I). 

Alkalinit}' 5  per  cent. 

Heat  at.." 155°  F. 


Signature 


Principles  of  Prescription  Writing  in  Laboratory  Feeding. — Let  it  be 
supposed  that  a  modified  milk  is  to  be  prescribed  for  an  infant  four 
months  old  with  a  normal  digestion  and  a  normal  weight  and  general 
development.  The  regular  prescription  blank  issued  by  the  laboratory 
can  be  used,  but,  of  course,  a  milk  prescription  can  be  written  as  one 
Would  write  for  a  drug.  The  physician  is  simply  required  to  Avrite  for  the 
percentage  of  each  ingredient  desired,  the  number  of  feedings,  the  amount 
in  each  feeding,  the  degree  of  alkalinity  and  temperature  at  which  the 
milk  is  to  be  heated.  The  calculations  are  made  at  the  laboratory.  The 
modifications  are  made  in  the  afternoon  from  cream  taken  from  the  morn- 


FEEDING.  219 

iiig  milking,  and  are  delivered  early  on  the  following  morning.  The  rules 
for  feeding  given  on  page  196,  will  serve  as  a  guide  to  the  strength  of  the 
food,  and  number  and  quaniity  of  the  feedings. 

If  whey-cream  mixtures  are  used  the  proiDortions  of  whey-proteids  and 
caseinogen  are  indicated  in  place  of  the  total  proteids.  (See  pages  220 
and  221.) 

If  modified  milk  by  the  quart  is  desired,  the  number  of  tubes  or  feed- 
ings, and  the  amount  at  each  feeding  are  not  indicated,  but  one  writes  for 
one  quart,  or  one  quart  and  one  pint,  as  the  case  may  be. 

"When  the  prescription  is  sent  to  the  office  the  clerk  copies  it  into  a 
book,  which  records  each  day's  feeding  of  each  individual  infant,  and 
then  translates  the  physician's  prescription  into  such  form  as  can  be 
readily  understood  by  the  modifying  clerks.  Of  course  this  form  may 
vary  in  ditferent  parts  of  the  world,  according  as  the  metric  or  the 
apothecary  system  is  in  use.  In  the  work  of  the  Ameiii-an  laboratories, 
although  the  prescriptions  are  written  by  the  physicians  in  the  metric 
system,  it  has  been  found  more  convenient,  when  delivered  to  the 
patrons  of  the  laboratory,  to  have  the  amounts  expressed  in  ounces  and 
drachms.  The  office  clerk,  after  translating  the  metric  percentages  into 
ounces  and  drachms,  copies  it  on  to  a  blank  called  the  modifying  clerk's 
prescription. 

The  prescription  is  then  placed  in  the  hands  of  the  modifying  clerk. 
who  combines  the  different  elements  of  the  prescription  by  means  of  the 
elemental  materials  which  have  been  brought  into  the  modifying-room 
from  a  different  part  of  the  laboratory. 

Practical  Limits  of  Laboratory  ^Iodificatiox. — We  have  requested 
physicians  to  write  their  prescriptions  within  certain  limits  as  to  the  per- 
centages of  the  fat,  sugar,  and  proteids,  and  to  allow  the  mineral  matter 
for  the  present  to  regulate  itself.  The  limits  which  up  to  the  present 
time  the  laboratory  has  found  it  necessary  to  place  on  the  prescriptions 
for  the  milk-modifiers,  and  within  which  the  modifying  clerk  is  supposed 
to  put  up  the  prescriptions,  are  shown  in  the  following  table : 

TABLE  48. 
Practical  Limits  of  Cream  Mixtures  in  Laboratory  ^fodifications. 

Fats,  any  percentage  from 0  to  4 

in  combination  with 

Sugars,  from 4  to  7 

and  with 
Proteids,  from 0.25  to  3.50 

The  results  obtained  from  combining  the  modifying  materials  used  by 
the  modifying  clerks  have  so  often  been  proved  to  be  practically  correct, 
that  we  can  assume  that  when  we  write  a  prescription  we  shall  obtain  in 
return  a  product  which  in  its  fats  and  proteids  comes  within  0.05  to  0.15  per 
cent,  of  that  called  for  in  the  prescription.  The  error  in  the  sugar  per- 
centage is  slightly  larger  as  a  rule. 


220   '  PEDIATRICS. 

The  Use  of  Whev  ^Mixtiiies  ix  Lahouatory  Feedixu. — Althougli  at 
present  our  knowledge  of  tlu^  comparative  elemental  percentages  of  the 
total  proteids  in  both  human  and  cow's  milk  is  inexact,  yet  we  can  at  least 
arrive  at  approximate  results,  with  much  benefit  to  an  infant  with  Aveak 
digestion,  in  our  endeavor  to  make  the  relative  proportion  of  the  whey- 
proteids  in  cow's  milk  correspond  to  what  is  probably  provided  by  nature 
for  purposes  of  nutrition  in  the  proteid  of  human  milk.  It  is  evident,  on 
examining  the  analysis  of  the  proteids  of  human  milk,  that  for  some  good 
reason  the  caseinogen  is  small  in  amount  in  comparison  with  the  whey- 
proteids. 

If  we  are  writing  a  prescription  which  calls  for  a  split  proteid  of  1  per 
cent.,  we  sliould  calculate  to  have  0.75  per  cent,  of  lactalbumin  and  0.25 
per  cent,  of  caseinogen.  A  prescription  calling  for  fat  3  per  cent.,  sugar  6 
per  cent.,  proteid  1  per  cent.,  alkalinity  5  per  cent.,  would  be  written  as 
follows  : 


R  Per  Cent.      Xumber  of  feedintis 9. 


Fat 3 

Sugar 6 

(a)  AVhey-proteids 0 

( b)  Caseinogen 0 


00         Amount  at  eacli  feeding.  .      75  c.c.  (  5  2 J) . 

00  Alkalinity 5  per  cent. 

75         Heat  at 155°  F. 

25  i 


If  an  ordinary  cream  mixture  calling  for  1  per  cent,  proteid  was 
prescribed,  the  proportions  would  be  0.75  caseinogen  and  0.25  whey- 
proteids.  To  give  the  same  amount  of  nitrogenous  food,  therefore,  we 
would  in  the  cream-mixtures  give  three  times  as  much  caseinogen  as 
in  the  whey  mixture,  making  it  proportionately  three  times  as  difficult  to 
digest. 

It  is  to  be  noted  that  although  the  total  proteid  percentage  in  the  milk 
for  an  infant  may  be  considerably  increased,  it  is  these  higher  percentages 
which  are  the  most  irrational  in  their  nutritive  values  in  the  early  months 
of  infancy,  if  we  hold  to  the  rule  that  the  caseinogen  should  be  present  in 
smaller  proportions  than  the  whey-proteids.  as  nature  has  provided  in  the 
majority  of  breast-milks. 

It  can  be  said,  however,  that  as  the  infant  grows  older  its  power  to 
digest  casein  becomes  proportionately  greater,  so  that  in  the  later  months 
of  infancy — the  sixth  to  the  twelfth — its  proteolytic  function  has  become 
adapted  to  this  change  in  the  ratio  of  the  caseinogen  and  lactalbumin,  so 
that  the  higher  total  proteids,  such  as  2.00,  2.50,  3,  and  3.50  per  cent., 
with  the  relatively  high  caseinogen  and  low  lactalbumin  become  the  proper 
nutritive  proportion  for  the  infant. 

The  point  especially  to  be  emphasized  is  that  in  the  early  months  of 
life,  which  demand  a  low  proteid  percentage,  we  can  by  the  use  of  whey 
obtain,  in   a   modified   milk,  the   same   proportions  of  lactalbumin   and 


FEEDING.  221 

caseinogen  which  we  find  hi  human  breast-milk  at  a  corresponding  period 
of  infancy.  Furthermore,  we  have  found  by  practical  use  of  these  mixt- 
ures in  a  large  number  of  cases  that  it  is  often  desirable  to  depart  from  the 
proportions  of  whey-proteids  and  caseinogen  found  in  human  milk.  After 
starting  with  a  prescription  calling  for  percentages  of  whey-proteid  0.25 
and  caseinogen  0.25,  it  is  now  our  custom  in  cases  of  difficult  proteid 
digestion  to  increase  the  whey-proteids  as  rapidly  as  possible  to  0.90  per 
cent.,  and  then,  maintaining  this  percentage,  to  increase  the  caseinogen 
0.25  per  cent,  from  time  to  time  and  as  rapidly  as  the  digestion  will 
permit,  until  it  has  been  raised  to  1.25  per  cent.  We  then  pass  to  the 
ordinary  total  proteid  of  1.75,  or  2.00  per  cent.,  according  to  the  indi- 
cations. A  further  consideration  of  the  use  of  whey  will  be  found  on 
page  191. 

The  prescriptions  calling  for  definite  proportions  of  caseinogen  and 
whey-proteids  which  can  now  be  filled  at  the  laboratory  are  as  follows : 

TABLE  49. 

Praclical  Limits  of  Wliey- Mixtures  in  Laboratonj  Modifications. 
Any  percentage  of  fat  from  1  to  4. 
Any  percentage  of  sugar  from  4  to  7. 
Any  of  the  following  combinations  of  whey-protei<ls  and  caseinogen  : 

AVhey-Proteids.  Caseinogen. 

Per  Cent.  Per  Cent. 

0.25  0.25 

0.50  0.25 

0.50  0.50 

0.75  0.25 

0.75  0.50 

0.75  0.75 

0.90  0.25 

0.90  0.50 

0.90  0.60 

0.90  0.75 

0.90  1.00 

0.75  1.25 

If  lime-water  above  5  per  cent,  is  desired  with  mixtures  of  3  per  cent, 
of  fat  or  over,  the  whey-proteid  percentage  cannot  practically  exceed  0.80, 
owing  to  the  fact  that  the  more  lime-water  is  used  the  less  will  be  the 
diluent  in  the  mixture,  and  the  maximum  amount  of  whey  which  can  be 
added  is  limited  to  the  number  of  ounces  of  the  diluent. 

ILLUSTRATIVE  CASES  OP  PERCENTAGE  FEEDING.— The 
following  cases  were  fed  under  our  direction  at  the  milk-laboratory  during 
the  first  year  of  their  lives,  and  merely  illustrate  the  changes  that  would 
naturally  be  made  in  the  food  during  this  period  in  the  life  of  a  healthy 
infant. 

The  first  case  was  a  male,  born  November  18,  1892.  The  table  shows 
the  record  of  its  weight  and  food  during  its  first  year : 


222 


PEDIATRICS. 


TABLE  50. 

Shoivhifl  Mana(jeme7>t  of  the  Food  and  hicreane   in  Weiglit  of  a  Hralf/n/  Lifaiit.  durlnff  the 
First  Fifty-Two  Weeks  of  its  Life. 


\ 

Weeks 

Amount 

Percentages  of  I''ood. 

Date. 

of 

"W^jntTT 

at  each 

Life. 

Feeding. 

Fat.  \ 

Sugar.  : 

Proteids. 

Lime-Water. 

1 

Grams,  t 

Lbs.  ' 

Oz. 

C.c. 

Oz. 

November  18 

1 
2 
3 
4 

3752 

8 

6 

30 
"45 

1 

2.00 
S.OO 

6.00 
6.00 

1.00 
1.00 

5.00 

5 

75 

n 

4.00 

7.00 

1.00 

10.00 

December  23 

6 

7 
8 

'4284" 

"9' 

"9 

90 

3 

5.00 

January  13 

9 

G'J44 

15 

"s 

'i65 

■  '3^' 

10 

11 

. 

12 

13 

120 

4 

Fel;)ruary  17 

14 
15 
16 
17 

6048' 

'  "13 

7 

135 

^\ 

4.00 

7.00 

2.00 

0 

March  17    

18 
19 
20 
21 
22 

6748 

15 

1 

150 

5 

0 

IS 

April  21     

23 
24 
25 
26 

7308 

16 

5 

165 

'o\ 

May  18 

27 

28 

7504 

16 

12 

180 

6 

4.00 

7.00 

2.50 

t^ 

Q 
^ 

29 

' 

3 

30 

£ 

31 

:S 

June  22 

32 
33 

7840 

17 

8 

210 

I 

'Ti 

0 

c3 

34 

4.00 

7.00 

3.00 

12.50 

03 

35 

r^ 

36 

c 

^ 

37 

4.00 

7.00 

2.50 

pR 

38 

.... 

3.50 

6.50 

1.50 

10.00 

39 

"iso 

"  '6  " 

4.00 

7.00 

2.00 

5.00 

August  17 

40 
41 

42 
43 
44 
45 

46 
47 

48 

'8820' 

'  I'o' 

'n 

225 

'J 

'4.66 
4.00 

Wh 

'  \im 

5.00 
ole  mi 

"'i.'o'o' 

3.00 
Ik. 

10.00 

12.50 

10.00 

5.00 

49 
50 

Wh 

ole  mi 

:1k  and 

oat-jelly. 

51 

November  9 

52 

9870 

22 

The  grammes  in  the  third  column  have  been  reduced  to  pounds  and  ounces  on  the  basis 
of  twenty-eight  grammes  to  the  ounce,  and  the  fractions  of  the  ounce  have  been  disregarded. 


FEEDING. 


223 


The  next  case  was   a  female,  born  November  1,  1892.     The   chart 
shows  the  Ime  of  growth  in  its  weight  from  birth  to  the  fifty-second  week 

of  its  life : 

CHAET  3. 


" 

Wt 

igh 

1      1 
tatBi 

'th 

3,1 

^01 

raj 

nm 

es 

1 

Date  of  Birth  Nov. 1st. 

CO 

§1 

o 

c 

§ 

o 

CI 

g 

-a 

i 

i 

1 

c 

1 

1 

i 

t 

1 

o 

i 

-J 

o 

1 

M 

i 

o 

1 

o 

O 

o 

4 

Actual  Weight 

1  " 

Gram's 

& 

o 

1 

3,180 

7 

1 

Nov. 

1 

l2_ 

3,180 

7 

J^ 

" 

8 

3 

3,180 

T] 

1 

" 

15 

\ 

4 

3,430 

7 

10 

'-• 

22 

\ 

5 

3,520 

7 

14 

" 

29 

\ 

6 

3,730 

8 

~5^ 

Deo. 

6 

— * 

\ 

1 

7 

3,980 

8 

14 

" 

13 

> 

\ 

8 

4,160 

9 

4 

" 

20 

\ 

V 

9 

4,340 

9 

10 

" 

27 

\ 

V 

10 

4,590 

10 

4 

Jan.}  3  j 

N, 

s. 

11 

4,870 

10 

14 

•-• 

10 

\ 

12 

5,060 

11 

4 

" 

17 

\ 

13 

5,270 

11 

12 

" 

24 

\ 

14 

5,560 

12 

6 

" 

31 

s 

N 

15 

5,870 

13 

1 

Te"D  1  7 

^ 

V 

16 

6,0TO 

13 

8 

'■     14 

\ 

. 

17 

6,300 

14 

1 

■■ 

21 

I 

18 

6,3/0 

14 

4 

" 

is 

\ 

s 

19 

6,510 

14 

8 

Mar 

7 

\ 

20 

6,650 

14 

13 

•• 

14 

S 

\ 

21 

6,930 

15 

7 

" 

21 

\ 

22 

6,980 

15 

9 

28 

\. 

23 

7.150 

15 

15 

Apr. 

4 

\ 

24 

7,240 

16 

2 

„ 

11 

\ 

25 

7,560 

16 

14 

" 

18 

\ 

26 

7,600 

16 

15 

" 

25 

\ 

s 

27 

7,800 

17 

6 

May 

2 

/ 

/ 

28 

7,730 

17 

4 

" 

9 

s 

\, 

29 

7.840 

17 

8 

" 

16 

V 

I 

30 

8,070 

18 

0 

" 

23 

\ 

31 

8,160 

18 

3 

" 

30 

\ 

32 

8,190 

18 

4 

June 

6 

s 

33 

8,490 

13 

15 

" 

13 

/ 

34 

8,470 

13 

14 

" 

20 

s, 

35 

8,700 

19 

6 

" 

27 

> 

36 

8,762 

19 

8 

July 

4 

\ 

37 

8,824 

19 

11 

" 

11 

ll 

38 

8,950 

19 

14 

" 

18 

ll 

39 

8,970 

20 

0 

" 

25 

1 

tl 

40 

8,930 

20 

1 

Aug. 

1 

1 

\ 

41 

9,060 

20 

4 

" 

8 

\ 

42 

9.140 

20 

6 

•■ 

15 

1 

\ 

<, 

43 

9,310 

20 

13 

" 

22 

/ 

^ 

44 

9.170 

20 

8 

" 

29 

\ 

\ 

45 

9.290 

20 

12 

Sep. 

5 

1 

\ 

46 

9,340 

20 

13 

12 

1 

V 

47 

9.470 

21 

2 

" 

18 

1 

v 

\ 

48 

9.640 

21 

9 

" 

26 

1 

49 

9,630 

21 

8 

Oct. 

3 

\ 

50 

9,740 

21 

10 

10 

\ 

51 

9,870 

22 

0 

17 

1 

52 

9,890 

22 

1 

24 

-<.  -;. 

t» 

OD    a> 

CD     o 

o 

- 

- 

|Eo 

M 

w 

c 

:^ 

K 

s 

s 

oj 

i3 

!3 

s 

£ 

S 

8 

g 

M 

to 

c^- 

O     00    o 

OD     O 

CO     O 

cx= 

o 

00 

o 

C 

ai 

c 

Ol 

C 

o 

CO 

K 

o. 

S 

-o 

5! 

CD 

^D 

t: 

* 

ta 

O 

31 

?eth 

al 

2M 

nths 

1  1 

w 

ight  at  B 

rth 

~  Fount?*' 

IC 

un 

il- 

_ 



224 


I'EDIATIIICS. 


The  following  talkie  records  the  quantity  and  quality  of  this  infant's 
food  during  the  first  year : 

TABLE  51. 

Showing  Manaxjement  uf  the  Food  and  Increase  of   Weighi  of  a  Healthy  Infayit  during  the 
First  Fifty-Two  Weeks  of  its  Life. 


Pekcentages  op  Food. 

Weeks 

Amount 

of 

Life. 

Feeding. 

Fat. 

Sugar. 

Proteids. 

Lime- 

Water. 

y.^i 

Graais. 

Lbs. 

07. 

Co. 

Oz. 

M  o 

^2 

November  1 

1 

8180 

7 

1 

■^  -^ 

November  8 

2 

3180 

t 

1 

60 

2 

2.00 

5.00 

00 

5.00 

^5- 

November  15    ... 

3 

3180 

7 

1 

60 

2 

4.00 

7.00 

1.00 

■"  -A 

November  22  ...  . 

4 

8430 

7 

10 

90 

3 

4.00 

7.00 

1.00 

.=  73 

November  29  ...  . 

5 

3520 

7 

14 

75 

2i 

3.00 

7.00 

1.00 

?r,'^ 

December  6 

G 

3780 

8 

5 

3.00 

6.00 

1.00 

22 

December  13 

,   7 

3980 

8 

14 

.... 

3.00 

7.00 

1.00 

December  20 

8 

4160 

9 

4 

90 

3 

4.00 

7.00 

1.00 

10.00 

S" 

December  27 

9 

4340 

9 

10     105 

3^ 

4.00 

7.00 

1.25 

5.00 

^-c 

January  3 

10 

4590 

10 

4! 

4.00 

7.00 

1.50 

S^ 

January  10 

11 

4870 

10 

14 

i-S 

January  17 

12 

5060 

11 

4 

s  _■ 

January  24 

13 

5270 

11 

12 

■^  o  5 

January  31 

14 

5560 

12 

6' 

Februarv  7   

15 

5870 

18 

1     120 

4 

12.50 

°      t.  5P 

Februarv  14 

16 

6070 

13 

8:   135 

4^ 

10.00 

2    ^1 

February  21  .    .  . 

17 

6300 

14 

1  ':  .... 

5.00 

^-% 

February  28 

18 

6370 

14 

4 

_  .    o  o 

March  7 

19 

6510 

14 

8' 

March  14 

20 
21 

6650 
6920 

14 
15 

18  i   150 

5 

4.00 

7.00 

2.00 

o  2.^ 

March  21 

7 

March  28 

22 

6980 

15 

9 

7  .%% 

April  4 

23 

7150 

15 

15 

Aprilll 

24 

7240 

16 

9 

>^    r>.5 

April  18 

25 

7560 

16 

14 

2  -SS 

April  25 

26 

7600 

16 

15 

:S   SS 

May  2 

27 

7800 

17 

6 

1   ^^ 

May  9 

28 

7730 

17 

4 

o   t,  S 

JZ     3-3 

May  16 

29 

7840 

17 

8 

bc  o:^ 

May  23 

30 

8070 

18 

0 

180 

6 

o    o  " 

May  30 

31 

8160 

18 

3 

L  SS 

June  6 

32 

8190 

18 

4 

June  13 

33 

8490 

18 

15 

195 

6* 

4.00 

7.00 

2.50 

ii      O   V   _• 

June  20 

34 

8470 

18 

14 

S  Z'^t 

June  27 

35 

8700 

19 

6 

z:  .=  s  tc 

July  4 

36 

8762 

19 

8 

O    o  o  8 

July  11     

37 

8824 

19 

11 

July  18 

38 
39 

8950 
8970 

19 
20 

14 
0 

^  =  = 

July  25 

?a  a; 

Ausjust  1 

40 

8980 

20 

0 

1  -2 

August  8 

41 

9060 

20 

3 

'■^%-~ 

August  15 

42 

9140 

20 

6 

5'SJI! 

August  22 

43 

9340 

20 

13 

Spf 

August  29 

44 

9170 

20 

7 

•^  ^  2 

September  5 

45 

9290 

20 

11 

■a  s  o 

September  12  ...  . 

46 

9340 

•20 

18 

September  19  ...  . 

47 

9470 

21 

2 

^o  ^ 

September  2G  .  .  .  . 

48 

9640 

21 

9 

i.^Tc 

October  8  

49 

9630 

21 

7 

g°l 

October  10  

50 

9740 

21 

10 

4.00 

6.00 

3.00 

^l-l 

October  17 

51 

9870 

22 

0 

Wh 

ole  mi 

Ik. 

oat- 

o  J^ 

October  24 

52 

9890 

22 

1 

Wh 

ole  mi 

Ik     and 

jolly. 

•P-  m 

The  grammes  in  the  third  column  have  been  reduced  to  pounds  and  ounces  on  the  basis 
of  twenty-eight  grammes  to  the  ounce,  and  the  fractions  of  the  ounce  have  been  disregarded. 


FEEDING.  225 

The  following  cases  have  a  practical  bearing  on  the  method  of  siibsti- 
tute  feeding  by  means  of  milk  laboratories. 

The  first  illustrates  how  important  it  is  to  be  able  to  vary  the  percent- 
ages of  the  different  elements  of  the  milk,  and  to  know  that  we  are 
obtaining  these  variations  exactly  as  they  are  ordered. 

An  infant  was  being  nursed  by  its  mother,  who  was  healthy,  and  who  had  an 
abundance  of  breast-milk.  Their  summer  home  was  by  the  sea-side,  in  a  healthy 
situation,  and  the  infant  was  surrounded  with  everything  that  could  be  desired  for 
perfect  hygiene.  The  infant  during  the  first  two  months  of  its  life  nursed  well,  thrived, 
and  was  perfectly  quiescent  in  its  daily  life.  When  it  was  three  months  old,  the  mother 
was  verj'  much  worried  by  some  family  matters  and  did  not  take  much  exercise.  The 
infant  now  began  to  have  colic,  and,  although  it  gained  in  weight,  it  was  very  restless 
and  cried  continuously.  An  analysis  of  the  mother's  milk  at  this  time  gave  the  follow- 
ing result : 

Fat 2.69 

Sugar 6. 15 

Proteids    3. 71 

Mineral  matter 0. 17 

Total  solids 12.72 

Water 87.28 

100.00 

The  indications  for  treatment  were,  of  course,  to  lessen  the  amount  of  mental  dis- 
turbance in  the  mother  and  to  make  her  exercise  more.  The  mother  having  followed 
these  directions,  the  symptoms  in  the  infant  soon  became  less  severe.  After  a  few  days, 
however,  the  unfavorable  symptoms  returned,  and  it  was  found  that  the  mother  had 
not  been  exercising  and  was  again  mentally  disturbed.  As  it  seemed  impossible  to 
regulate  the  function  of  the  mammary  gland  under  these  circumstances,  it  was  decided 
to  feed  the  infant  from  the  milk-laboratory.     The  following  prescription  was  ordered  : 

Prescriptiox  3. 

R   Fat 3.50 

Sugar 6. 50 

Proteid:^ 1.00 

Eeaction Slightly  alkaline. 

Heated  to 75°  C.  (167°  F.). 

Eight  tubes,  each  holding 90  c.c.  (3  ounce?) . 

The  infant  digested  this  food  perfectly,  had  no  colic,  and  again  became  tranquil. 
As,  however,  it  only  made  a  slight  gain  in  weight  during  the  first  two  or  three  weeks  of 
this  substitute  feeding  we  changed  the  prescription  t')  the  following  one  : 

PfiEStRlPTIOX   4. 

R   Fat 4.00 

Sugar "-'JO 

Proteids l-on 

On  taking  this  food  the  iufant  began  to  make  regular  gains  in  weight,  and  con- 
tinued to  thrive  until  it  was  four  months  old,  when  it  was  brought  back  to  its  city 
home,  where  it  was  subjected  to  many  of  the  annoyances  which  are  so  frequently  seen, 
and  which,  although  somewhat  disastrous  to  the  infant,  tend  to  advance  our  knowledge 
of  substitute  feeding.      The  infant  was  surrounded  with  too  much  excitement.  ;nid  was 

]5 


226  PEDIATRICS. 

exposed  to  unnecessary  changes  of  temperature  in  its  liome.  During  the  process  of 
removal  from  the  sea-side  to  the  city  it  caught  a  slight  cold,  and  had  intestinal  symp- 
toms characterized  by  those  discharges  from  the  bowels  and  undigested  food.  This 
condition  was  easily  obviated  in  a  few  days  by  simply  changing  the  prescription  at  the 
laboratory  to  the  following  one  : 

Prescription'  5. 

R  Fat 2.50 

Sugar 500 

Proteids 100 

Lime-water 10.00 

Under  this  treatment  the  food  was  again  fairly  well  digested,  the  discharges 
lessened  in  frequency,  and  were  of  a  better  character.  The  infant,  however,  during 
this  sickness  had  lost  over  224  grammes  (about  h  pound)  in  weight. 

At  this  juncture  the  grandmother  of  the  infant  so  influenced  the  mother  that  she 
insisted  upon  having  a  wet-nurse  procured  at  once.  Although  we  did  not  ajjprove  of 
this  change,  the  family  were  so  urgent  in  their  demands  for  a  wet-nurse  that  we  procured 
one  for  them.  This  wet-nurse  was  nursing  her  own  infant  and  another  infant  at  the 
Infants'  Hospital.  Both  infants  were  thriving  in  every  way.  An  analysis  of  this  wet- 
nurse's  milk  gave  the  following  results  : 

Fat 2.92 

Sugar. 6.20 

Proteids 4.62 

Mineral  matter 0.16 

Total  solids 13.90 

Water 86. 10 

100.00 

The  milk  for  this  analysis  was  taken  from  the  middle  of  the  nursing.  The  per- 
centage of  proteids  was  so  high  that  we  did  not  dare  to  allow  the  foster-infant  to  be  put  to 
he  breast  at  once.  We  therefore  endeavored  to  regulate  the  percentages  of  the  elements 
of  the  wet-nurse's  milk  in  the  usual  way.  At  the  end  of  two  days  another  analysis  of 
her  milk  was  made,  with  the  following  result : 

Fat 3.39 

Sugar 5.95 

Proteids 4.78 

Mineral  matter 0.21 

Total  sohds 14.33 

Water 85.67 


100.00 


The  extraordinarily  high  percentage  of  proteids  in  this  analysis  made  me  abso- 
lutely refuse  to  allow  the  foster-infant  to  begin  with  its  nursing  from  the  wet-nurse. 
The  family,  however,  were  very  impatient,  and  argued  that,  as  the  other  two  infants 
were  gaining  in  weight,  digesting  well,  and  looking  remarkably  ruddy,  it  must  be  a 
good  milk  which  they  were  receiving  from  the  wet-nurse. 

Two  days  later,  although  the  foster-infant  was  decidedly  improving  on  the  substitute 
food  from  the  laboratory,  it  happened  to  lose  30  grammes  (about  1  ounce)  in  weight, 
and  the  family  then  insisted  that  this  wet-nurse  should  be  tried.  Another  analysis  of 
the  wet-nurse's  milk  was  then  made,  and  showed  that  the  percentage  of  the  proteids 
had  been  reduced  to  betweeri  3  and  4. 


FEEDING.  227 

We  had  already  endeavored  to  find  other  wet-nurses  whose  milk  would  better  corre- 
spond to  what  the  infant  needed,  but  was  unsuccessful  in  obtaining  any  the  analysis  of 
whose  milk  showed  the  percentage  of  the  proteids  to  be  below  3. 

The  analyses  of  the  milk  of  two  of  these  wet-nurses  were  as  follows  : 

I'at 3.88 

Sugar 6.55 

Proteids 3.14 

Mineral  matter 0. 14 

Total  solids 13. 71 

Water 86. 29 

100.00 

Fat 3.39 

Sugar 4.50 

Proteids 4. 70 

Mineral  matter 0. 18 

Total  solids 12. 77 

Water 87.23 

100.00 

The  first  wet-nurse  was  then  brought  to  the  footer-infant's  home,  and  the  infant  was 
put  to  the  breast.  It  absolutely  refused  to  take  the  breast  for  twelve  hours,  although  it 
was  crying  with  hunger.  Finally  it  was  induced  to  nurse,  but  immediately  after  the 
nursing  had  an  attack  of  colic.  These  attacks  of  colic  were  moderately  severe,  and 
occurred  after  each  nursing.  The  infant  soon  appeared  to  like  the  milk  and  took  it 
eagerly  at  the  regular  nursing  intervals.  In  twenty-four  hours  from  the  time  when  the 
infant  began  to  nurse  its  bowels  were  again  affected.  The  number  of  discharges  became 
frequent,  and  the  milk  evidently  was  not  being  digested  well.  These  conditions  lasted 
for  several  days,  when  it  was  found  that  the  infant  had  lost  over  480  grammes  (about  1 
pound)  in  weight.  As  the  severity  of  the  colic  was  increasing,  and  as  the  infant  had 
lost  its  color,  the  mother  agreed  to  have  the  feeding  by  the  wet-nurse  discontinued. 
We  then  wrote  the  following  prescription  to  be  put  up  at  the  laboratory  : 

Prescription  6. 

R   Pat 2.00 

Sugar 5.00 

Proteids 1.00 

Lime-water 10.00 

To  be  heated  to 75°  C.  (167°  F.). 

This  mixture  was  given  to  the  infant.  In  twenty-four  hours  the  number  of  dis- 
charges from  the  bowels  grew  less,  and  in  a  few  days  became  almost  normal.  It  began 
to  gain  in  weight,  and  though  seeming  very  hungry,  looked  better  and  ceased  to  have 
colic. 

The  prescription  was  then  changed  to  the  following  one  : 

Prescription  7. 

R   Fat 3.00 

Sugar 6.00 

Proteids 1.00 

Lime-water 5.00 

On  taking  this  food  the  infant  began  to  make  regular  gains  in  weight,  but  still 
seemed  hungry,  so  that  at  the  end  of  another  week  the  prescription  was  changed  to  the 
following  one  : 


228  PEDIATHICS. 

Prescription  8, 

R     Fat 4.00 

Sugar 7.00 

Proteids l-'^O 

The  infant  now  improved  steadily.  It  made  the  normal  average  daily  gains  in 
weight,  and  soon  recftvered  its  color  and  former  strengtii.  From  this  time  it  continued 
to  thrive. 

This  case  is  interesting  in  many  ways.  It  was  very  evident  that  a  per- 
centage of  proteids  over  8  was  more  than  this  especial  mfant  could  digest. 
It  therefore  had  to  be  weaned  from  its  mother.  The  wet-nurse's  milk, 
which  was  agreeing  perfectly  with  her  own  mfant  and  with  another  infant 
which  she  Avas  nursing  at  the  hospital,  had  a  percentage  of  proteids  be- 
tween 3  and  4.  As  we  knew  from  our  experience  with  the  mother's  milk 
that  this  high  percentage  of  proteids  would  not  agree  with  the  infant,  we 
were  not  surprised  to  find  that,  instead  of  agreeing  with  it,  it  made  it  sick. 
This  case  substantiates  the  statement  that,  while  there  are  many  varieties 
of  good  milk,  there  are  also  many  infants  who  cannot  thrive  on  them  all, 
but  only  upon  such  as  suit  their  individual  digestive  powers. 

It  is  interesting  also  to  record  in  this  case  that  as  the  infant  grew  older, 
it  was  found  that  the  percentage  of  the  proteids  could  be  increased  in  its 
food  without  harming  its  digestion,  and  that  by  the  time  it  was  eight 
months  old  it  was  having  in  its  food  percentages  of  proteids  between  3 
and  4,  the  very  percentages  which  caused  such  serious  digestive  disturb- 
ance when  it  was  younger.  When  it  was  ten  months  old  it  was  able  to 
digest  4  per  cent,  of  proteids  in  its  food. 

This  case  as  a  whole  so  well  illustrates  the  use  of  the  accurate  feeding 
by  means  of  a  milk-laboratory  that  it  is  hardly  worth  while  to  multiply 
instances  of  its  value.  We  believe  that  by  the  establishment  of  these 
laboratories  a  new  era  has  been  entered  upon  in  the  province  of  infant 
feeding,  and  one  which  will  enable  us  to  produce  results  which  have  never 
efore  been  obtained.^ 

Feeding  of  Average  Infants  born  at  Term. — When  an  infant  is  born 
at  term,  is  of  normal  development  and  weight,  and  is  healthy,  we  are  in 
the  habit  of  regulating  the  quantity  of  its  food  according  to  the  table  on 
page  196. 

At  about  the  tenth  or  eleventh  month  we  usually  begin  to  give  at  first 
one  and  then  two  meals  daily  of  equal  parts  of  oat-jelly,  with  plain  cow's 


1  The  first  laboratory  for  the  exact  modification  of  milk  that  has  been  established 
in  the  world  was  opened  to  the  public  in  1891  in  Boston,  under  the  name  of  the  Walker- 
Gordon  Laboratory.  The  development  of  the  system  of  modification  in  percentages 
and  the  establishment  of  this  as  well  as  of  eighteen  other  laboratories  in  different 
parts  of  the  country  and  in  London,  which  now  represent  the  Walker-Gordon  Com- 
pany, was  accomplished  by  the  joint  efforts  of  Mr.  G.  E.  Gordon,  Mr.  G.  H.  Walker, 
and  Mf.  J.  U,  Wntf^rhouse. 


FEEDING.  220 

milk  heated  to  68.3°  C.  (155°  F.),  and  a  little  salt  added  according  to  the 
infant's  taste  at  the  time  of  the  feeding.  Freshly  prepared  barley  or 
wheat  can,  if  preferred,  be  given  with  milk  at  this  age. 

In  the  twelfth  month  we  usually  accustom  the  infant  to  taking  a  little 
bread  one  day  old  with  its  milk,  and  to  be  fed  from  a  spoon,  so  that  by 
the  time  it  is  a  year  old  it  is  taking  bread  and  milk  for  its  breakfast  and 
supper,  and  oat-jelly  and  milk  for  the  three  middle  meals. 

Influence  of  Fat  on  the  Color  of  F^cal  Dejections. — We  have  con- 
sidered it  of  some  scientific  and  practical  interest  to  record  the  color  of 
the  faecal  discharges  which  corresponds  apparently  to  the  percentage  of 
fat  in  human  milk  and  in  the  corresponding  modified  milk.  Plate  III.,  3 
and  4,  facing  p.  77,  shows  the  color  of  the  normal  yellow  dejections  of  two 
infants  who  were  being  nursed  by  their  healthy  mothers  and  were  them- 
selves digesting  well  and  thriving. 

Plate  III.,  8  and  9.  facing  p.  77,  represents  the  color  of  the  normal 
yellow  dejections  of  two  infants  who  were  fed  on  a  modified  milk  which 
corresponded  to  average  human  milk.  The  percentages  of  the  fats,  sugar, 
and  proteids  in  this  modified  milk  were  respectively  4,  7,  and  1.  The 
infants  were  digesting  well  and  thriving. 

The  resemblance  in  color  and  consistency  between  the  f«cal  discliarges 
resulting  from  human  milk  and  from  modified  milk  in  which  the  percent- 
age of  fat  was  4  is  very  striking. 

Plate  III.,  7,  facing  p.  77,  shows  the  fsecal  discharges  of  a  healthy  in- 
fant fed  on  a  modified  milk  having  a  percentage  of  3  for  its  fat,  6  for  its 
sugar,  and  1  for  its  proteids.     The  color  of  the  yellow  is  much  lighter. 

Tliis  change  of  color  is  still  more  strikingly  illustrated  in  Plate  III.,  6, 
facing  p.  77,  in  which  the  infant  was  taking  modified  milk  composed  of 
fat  2  per  cent.,  sugar  5  per  cent.,  and  proteids  1  per  cent.,  and  in  which 
the  resulting  fsecal  discharge  had  a  very  much  lighter  color  than  in  the 
other  cases. 

Artificial  Foods  for  Infants. — It  would  seem  hardly  necessary  to 
suggest  that  the  proper  authority  for  establishing  rules  for  substitute  feed- 
ing should  emanate  from  the  medical  profession  and  not  from  proprietors 
of  the  proprietary  foods.  There  are,  Iiowever,  many  physicians  in  practice 
to-day  whose  only  knowledge  of  infant  feeding  is  that  (>btained  from 
travelling  agents  of  various  commercial  houses.  The  busy  practitioner, 
conscious  of  his  ignorance  of  the  subject  grasps  at  a  method  which  on 
paper  is  simple  and  easily  understood.  If  in  practice  the  method  fails  he 
turns  to  another  food  and  still  another,  until  the  whole  list  has  been  tried. 
Still  failing  he  pronounces  the  case  hopeless  and  sends  it  to  some  infant 
specialist  for  treatment. 

All  cases  do  not  fail,  however ;  some  of  the  foods  may  be  in  every  way 
successful  and  in  these  cases  the  particular  brand  of  food  the  baby  happens 
to  be  on  gets  the  full  credit  of  the  results,  the  influence  of  the  cow's  milk 
which  is  used  in  making  up  the  mixture  being  wholly  disregarded. 


230  PEDIATRICS. 

The  leading  pediatrists  in  tliis  country  are  united  in  condemning  the 
use  of  proprietary  foods  as  such.  There  is  not  one  which  alone  and  with- 
out the  addition  of  fresh  cow's  milk  can  be  called  a  suitable  food  for 
infants.  Cow's  milk  must  be  the  basis  of  all  substitute  feeding  and  the 
principles  by  which  it  is  modified  and  adapted  to  the  use  of  individual 
infants  must  be  learned  sooner  or  later  by  those  who  wish  to  feed  babies 
intelligently  and  with  the  greatest  prospect  of  success.  Nothing  is  more 
dangerous  or  comes  nearer  to  malpractice  in  infant  feeding  than  to  tell  a 
mother  with  a  sick  child  to  buy  such  and  such  a  food  and  to  follow  the 
directions  on  the  can,  and  yet  thousands  of  lives  are  sacrificed  each  year 
by  careless  advice  of  this  nature. 

If  proprietary  foods  are  used  at  all  they  should  be  prescribed  with  a 
just  appreciation  of  the  nature  of  the  food  and  of  the  proportions  of  the 
ingredients  which  are  being  added  to  the  milk.  Their  use  does  not  do 
away  with  the  necessity  of  modification  of  the  milk  as  any  one  can  see 
who  has  grasped  the  principles  of  percentage  feeding.  If  in  a  successful 
case  of  percentage  feeding  we  should  attribute  the  results  entirely  to  the 
milk-sugar  used  without  giving  credit  to  the  other  elements  of  the  food, 
we  should  be  putting  ourselves  in  the  illogical  position  of  most  of  the 
proprietors  of  baby  foods,  who  attribute  the  effects  of  feeding  to  the  use 
of  their  particular  food. 

Proprietary  foods  are  never  fresh.  Those  that  are  compounded  with 
milk  give  no  guarantee  as  to  the  purity  of  the  original  milk-supply.  Most 
of  them  contain  sugars  or  partially  dextrinized  starch  in  amounts  greatly 
in  excess  of  what  we  consider  to  be  the  rational  diet  in  the  first  year,  while 
the  fats  are  almost  invariably  too  low  for  proper  nutrition. 

In  practical  feeding,  as  we  have  seen,  the  majority  of  healthy  infants. 
after  the  first  few^  w^eeks,  thrive  best  upon  fat  and  proteids  in  the  propor- 
tions of  4  to  1.50  or  4  to  2.  In  eight  of  the  most  commonly  used 
proprietary  foods  the  proportions,  fat  and  proteids,  are  4:11;  0:11;  1: 
5  ;  8  :  18  ;  1:11;  1  :  14  ;  12  :  14  ;  and  7  :  10.  We  see,  therefore,  how 
ipossilDle  it  is  with  any  of  these  preparations  to  obtain  the  natural 
proportion  present  in  human  milk  and  in  the  majority  of  prescriptions  for 
modified  milk. 

We  should  recognize  that  proprietary  foods  do  not  all  belong  to  one  class. 
There  is  the  group  of  condensed  milks  which  consist  chiefly  of  evapor- 
ated sweetened  milk,  in  some  of  which  a  dextrinized  flour  has  been  added. 

Another  group  comprises  malted  foods  which  are  obtained  by  the 
action  of  malt  on  cereals.  These  consist  mostly  of  carbohydrates  in  the 
form  of  dextrin,  dextrose  and  maltose.  These  foods  are  intended  to  be 
mixed  with  cow's  milk.  They  fulfil  a  function  similar  to  that  of  milk- 
sugar  in  ordinary  modifications,  and  are  used,  successfully  or  not,  accord- 
ing to  the  intelligence  with  which  they  are  combined  with  proper 
proportions  of  fresh  milk  and  cream. 

Another  class  consists  almost  entirely  of  cereal  flour  in  the  form  of 


FEEDING.  231 

unchanged  starch  with  the  natural  cereal  proteids.  This  class,  of  which 
the  prepared  barley  flour  is  an  example,  cannot  be  looked  upon  as  sub- 
stitute foods,  but  only  as  convenient  preparations  for  making  the  cereal 
waters  and  jelly  for  use  when  the  infant  reaches  the  age  at  which  starch 
becomes  an  important  addition  to  its  dietary. 

The  use  of  proprietary  foods  is,  therefore,  in  our  opinion  to  be  dis- 
couraged in  that  they  mislead  both  physicians  and  mothers  as  to  the 
essential  principles  of  infant  feeding,  even  when  combined  with  milk, 
whereas,  used  alone,  they  are  common  causes  of  severe  disturbances  of 
digestion  and  nutrition. 

Matzoon. — Matzoon  is  a  fermented  milk  made  by  the  action  of  an 
imported  ferment,  probably  a  form  of  yeast,  upon  cow's  milk.  The 
milk  is  first  boiled  for  the  purpose  of  sterilization,  the  matzoon  ferment 
is  added,  and  the  fermentation  is  begun  at  a  temperature  of  about  40.5°  C. 
(105°  F.)  and  continued  in  an  open  vessel  for  twelve  hours.  The 
temperature  is  gradually  cooled  to  about  21.1°  C.  (70°  F.)  and  the  milk  is 
bottled  and  kept  on  ice.  It  is  ready  for  use  in  twenty-four  hours.  If 
used  for  infant  feeding,  it  should  be  diluted  with  water  and  fed  with  a 
spoon,  as  it  is  too  thick  to  be  drawn  from  a  bottle. 

KuMYss. — The  best  formula  for  the  domestic  manufacture  of  kumyss 
is  that  described  by  Holt :  Take  one  quart  of  fresh  milk,  half  an  ounce 
of  sugar,  two  ounces  of  water,  and  a  piece  of  fresh  yeast-cake  half  an 
inch  square.  These  materials  are  put  into  wired  bottles  and  kept  at  a 
temperature  of  15.5°  C.  (60°  F.)  or  21.1°  C.  (70°  F.)  for  one  week,  shaking 
five  or  six  times  a  day.     The  milk  is  then  put  upon  the  ice  until  used. 

Matzoon,  kumyss,  and  similar  preparations,  in  the  light  of  recent  re- 
searches and  advances  which  have  been  made  in  the  feeding  of  infants  and 
children  with  modified  milk,  may  no  longer  be  considered  as  advisable  foods. 

Butter-milk. — The  use  of  butter-milk  in  cases  of  chronic  intestinal 
indigestion  and  in  acute  diarrhoeas  has  been  highly  commended  by 
Babinsky  and  others.     Its  composition  as  given  by  Vieth  is : 

Fat 0.50 

Milk-sugar 4.06 

Lactic  acid 0.80 

Proteids 3.60 

Inorganic  salts ....     .... 0.75 

Water 90.39 

The  chief  difference  between  butter-milk  and  whole  milk  are  the  same 
traces  of  fat  and  the  very  high  percentage  of  lactic  acid  in  the  former. 

As  has  been  shown  on  page ,  the  presence  of  considerable  qualities  of 

lactic  acid  render  the  conditions  unfavorable  for  the  development  of  pu- 
trefactive bacteria.  This  and  the  low  percentage  of  fat  explain  to  a  large 
extent  the  reason  for  beneficial  effects  claimed  for  butter-milk  as  a  food  for 
infants.  At  best,  owing  to  its  low  fat  content,  it  should  be  used  only  as  a 
temporary  substitute  for  modified  cow's  milk.  Personally  we  believe  its 
value  as  an  infant  food  has  been  greatly  over  estimated  by  some  writers. 


232  I'EDlATRirs. 

SECOND   NUTRITIVE   PERIOD. 

During  the  tenth  and  twelfth  months  of  life  the  amylolytic  function  of 
the  infant  has  become  almost  fully  developed.  In  accordance  with  the 
rule  regarding  the  use  of  the  different  functions, — namely,  that  a  function 
should  not  be  taxed  before  it  is  developed,  but  that  when  its  development 
is  almost  completed  it  should  be  brought  into  use, — we  should  in  the  lat- 
ter part  of  the  first  year  begin  to  use  that  function  of  the  digestive  tract  by 
means  of  which  the  amylaceous  elements  of  the  food  are  converted  into 
sugar. 

x4t  this  age  the  percentage  of  sugar  should  gradually  be  reduced  in  the 
modified  milk  and  the  percentage  of  proteids  increased  until  the  whole 
milk  is  found  to  be  digested,  which  may  be  at  any  time  between  the  twelfth 
and  fourteenth  months.  The  reason  for  changing  the  relative  percent- 
ages of  these  elements  is  that  the  power  to  digest  proteids  has  much  in- 
creased during  the  latter  part  of  the  first  year.  The  capacity  for  digesting 
a  high  percentage  of  sugar  is  j  ust  as  great  at  this  period  as  at  an  earlier 
one,  but  the  amount  of  sugar,  given  directly  as  such,  in  a  modified  milk, 
which  is  required  in  the  later  is  not  so  great  proportionately  as  in  the 
earlier  period.  A  large  portion  of  the  sugar  which  is  needed  for  nutrition 
in  this  later  period  is  intended  to  be  introduced  into  the  economy  by  means 
of  a  new  element  in  the  food, — starch.  A  certain  amount  of  sugar  is,  as 
before,  directly  introduced  into  the  gastro-enteric  tract  from  the  milk-sugar 
of  the  milk,  and  the  starch  when  converted  into  sugar  supplies  the  re- 
maining portion  of  sugar  needed  for  nutrition.  In  a  normal  infant  with 
normal  digestive  functions  a  considerable  percentage  of  starch  can  be  di- 
gested and  absorbed  with  benefit  in  the  eleventh  and  twelfth  months.  It 
is  well,  however,  at  first  not  to  give  immediately  a  high  percentage  of 
starch  in  the  mixture,  and  also  not  to  ignore  the  fact  that  the  various 
cereals  contain  fat  and  proteids  as  well  as  starch.  Consideration  must 
also  be  paid  to  what  the  total  resulting  percentage  of  sugar  will  be  w^hen 
/-'"Contributed  by  the  converted  starch  and  the  milk-sugar  in  the  milk.  In  this 
way  a  gradual  change  of  percentages  can  be  made  in  the  infant's  food  until 
its  digestive  capabilities  have  become  adapted  to  the  food  values  indicated 
for  digestion  in  the  second  year.  This  indication  is  for  a  higher  fat,  sugar, 
and  proteid  percentage  in  the  food  and  for  whole  milk,  preferably  from 
Holstein  cows.  When,  however,  the  digestion  is  -weak,  a  modified  milk 
can  be  continued  into  the  second  year. 

Any  additional  sugar  which  may  be  needed  with  the  food  can  at  this 
time  be  in  the  form  of  cane-sugar  rather  than  milk-sugar.  The  starch  can 
best  be  obtained  from  preparations  of  oats,  barley,  and  wheat.  There  is 
a  larger  percentage  of  starch  m  oats  than  m  barley.  It  is  also  more  nu- 
tritious in  every  respect,  as  it  contains  a  larger  percentage  of  fat. 
The  starch  in  oats  takes  a  somewhat  longer  time  to  be  converted  into 
sugar  than  does  that  of  barley,  so  that  in  the  case  of  an  infant  whose 


FEEDING.  233 

amylolytir  function  is  not  fully  developed  or  is  somewhat  weak,  prepa- 
rations of  barley  will  be  better  to  begin  with,  because  they  do  not  intro- 
duce so  high  a  percentage  of  starch  into  the  food,  and  also  because  the 
starch  will  be  more  readily  converted  into  sugar.  Preparations  of  oats 
seem  to  be  the  best  form  of  food  to  be  added  to  the  milk  w^hen  the  infant 
has  reached  a  period  at  which  it  needs  a  change  in  the  character  of 
its  food. 

We  have,  therefore,  in  preparations  of  oats,  both  for  purposes  of 
weaning  and  for  establishing  a  new^  regimen  of  diet  for  the  infant,  a  food 
which  in  combination  with  cow's  milk  satisfies  completely  the  demands 
which  the  digestive  functions  at  this  period  are  making  for  a  perfect  nutri- 
ment. In  using  cereals  in  the  food  they  are  best  at  first  reduced  to  a 
jelly,  as  described  on  page  184. 

The  second  nutritive  period  may  be  reckoned  to  last  from  the  twelfth 
to  the  tw^enty-eighth  or  thirtieth  month  of  life.  That  is  about  the  second 
half  of  the  period  which  we  are  in  the  habit  of  calling  infancy.  It  also 
includes  the  time  when  the  last  four  teeth  of  the  first  set  appear.  In  this 
second  nutritive  period  the  element  of  variety  in  the  food  becomes  impor- 
tant. It  is  undoubtedly  important  that  the  actual  nutritive  values  of  the 
food  which  it  is  best  to  give  to  infants  in  this  period  be  considered,  but  it 
is  much  more  important  that  special  attention  be  paid  to  its  variety. 
Foods  should  be  given  which  while  containing  a  fair  percentage  of  nutri- 
tive elements  yet  differ  in  the  combination  of  these  elements  to  such  a 
degree  that  they  fulfil  the  requirements  of  this  period  of  life.  It  is  best  to 
increase  gradually  the  variety  of  articles  of  diet  from  the  tw^elfth  to  the 
twentieth  month,  ahvays  adapting  the  food  to  the  especial  infant.  Thus, 
some  infants  may  be  able  to  digest  and  assimilate  proportionately  large 
quantities  of  starch ;  others  may  both  need  and  digest  larger  proportions 
of  the  proteids  or  of  sugar  than  the  infants  first  spoken  of 

Between  the  twelfth  and  thirteenth  months  the  infant  should  have 
five  meals  during  the  day.  At  this  time  it  is  well  to  accustom  it  to  take 
its  food  from  a  spoon,  and  as  soon  as  possible  to  omit  feeding  from  the 
bottle.     The  five  meals  should  be  arranged  in  the  following  manner : 

For  breakfast,  bread  and  cow's  milk,  slightly  warmed. 

For  lunch,  equal  parts  of  oat-jelly  and  cowl's  milk,  warmed,  with  a 
little  salt  added  according  to  the  infant's  taste. 

This  meal  of  oat-jelly  should  be  repeated  in  the  middle  of  the  after- 
noon. 

In  the  middle  of  the  day,  broth  of  some  kind,  either  chicken  or  mutton, 
carefully  prepared  so  as  to  be  free  from  fat  on  its  surface,  can  be  given 
with  some  bread. 

The  fifth  meal  should  be  given  in  the  latter  part  of  the  afternoon,  and 
should  consist  of  bread  and  milk. 

In  some  cases  it  is  impossible  to  make  infants  swallow  bread  for  a 
long  period  after  the  usual  time  of  twelve  to  thirteen  months.     At  times 


234  PEDIATRICS. 

it  is  not  until  they  are  two  and  one-half  to  three  years  old  that  they  can 
be  induced  to  take  bread.  In  these  cases  we  must  feed  them  according  to 
our  judgment  of  the  individual  case. 

When  the  infant  is  fourteen  to  fifteen  months  old,  it  can  have  some 
thoroughly  boiled  rice  added  to  the  broth  in  the  middle  of  the  day. 

When  the  infant  is  sixteen  months  old,  it  can  have  a  small  amount  of 
butter  on  its  bread.  When  it  is  fifteen  to  eighteen  months  old,  it  can 
have  a  thoroughly  baked  white  potato,  mixed  with  butter  and  salt,  added 
to  its  mid-day  meal  of  bread.  At  the  same  age  soft-boiled  eggs  can  become 
part  of  its  diet,  but  some  infants  have  a  decided  idiosyncrasy  against  eggs, 
and  they  may  not  be  tolerated  until  the  end  of  the  second  or  first  part  of 
the  third  year. 

There  are  not  many  fruits  which  should  be  given  to  the  infant  in  its 
second  year.  A  baked  apple  can  be  given  at  the  evening  meal  when  the 
infant  is  fourteen  to  fifteen  months  old ;  or,  for  variety,  the  apple  can  be 
made  into  a  simple  sauce,  never,  however,  having  the  sauce  made  with 
much  sugar.  When  peaches  are  in  season,  a  ripe  peach  can  often  be 
given  with  benefit,  especially  if  the  infant  is  inclined  to  be  constipated,  and 
the  expressed  juice  of  oranges  and  stewed  prunes.  Other  fruits  should 
be  avoided,  as  they  are  not  necessary  for  the  infant's  nutrition  and  at 
times  produce  serious  trouble. 

This  is  the  diet  which  is  sufficient  for  the  infant  during  the  second 
nutritive  period.  It  is  important  for  the  subsequent  integrity  of  the  in- 
fant's digestion  and  general  nutrition  that  the  parents  should  insist  that  no 
other  articles  of  food  be  employed,  except  such  as  are  similar  to  those 
which  have  been  mentioned, — namely,  the  cereals  in  a  variety  of  forms, 
according  to  the  taste,  judgment,  and  knowledge  of  cooking  which  exists 
in  the  special  household.  For  instance,  preparations  of  wheat  and  barley 
cooked  in  various  forms  may  be  given  in  place  of  oatmeal.  Bread  also  in 
different  forms  may  be  given.  The  crust  of  French  bread  is  easily  digested, 
and  is  supposed  to  have  less  starch  in  proportion  to  its  gluten  than  the 
^ — usual  home-made  bread.  It  is  well  to  begin  with  some  form  of  bread  of 
this  kind  when  we  are  getting  the  infant  accustomed  to  take  starch  in  the 
form  of  bread.  If  it  is  constipated,  Graham  bread  and  preparations  of  rye 
will  also  be  found  useful,  and  cream  may  be  added  to  the  milk.  Fresh  ' 
bread  should  never  be  given,  and  bread  one  day  old  is  the  preferable  form 
which  should  be  provided. 

The  infant  should  never  be  given  cake  or  candy  even  to  taste.  It  is 
necessary  to  state  this  very  decidedly,  because  it  is  an  erroneous  view 
which  is  held  by  most  mothers  that  it  can  do  no  harm  to  give  occasionally 
to  an  infant  in  its  second  year  of  life,  or  to  a  young  child,  a  little  candy 
or  a  little  cake.  This  may  be  true  so  far  as  the  immediate  effect  these 
articles  may  have  on  the  digestion  is  concerned,  but  it  is  of  far  more  im- 
portance that  the  infant  should  not  have  its  taste  perverted  from  those 
articles  of  diet  which  are  best  for  its  nutrition.     These  new  articles  appeal 


FEEDING.  235 

more  strongly  to  its  sense  of  taste,  and  allow  it  to  know  that  there  is  some- 
thing  which  tastes  more  agreeable  than  the  food  which  it  is  accustomed  to 
have.  When  an  infant  has  acquired  a  taste  for  cake  or  candy,  it  will  cease 
to  enjoy  the  food  by  which  the  development  will  be  best  perfected.  It  is,  in 
fact,  kinder  to  the  infant  never  to  allow  it  to  taste  cake  or  candy.  When 
these  articles  are  withheld,  it  will  continue  to  have  a  healthy  appetite  and 
taste  for  necessary  and  proper  articles  of  food. 

Broths  can  be  prepared  in  the  following  manner : 

Chicken  Broth  and  Jelly. — A  fowl  weighing  about  three  pounds,  with 
two  tablespoonfuls  of  rice,  two  quarts  of  cold  water,  and  salt  and  pepper, 
should  be  boiled  for  two  hours  and  until  the  fluid  has  boiled  down  to  one 
quart.  The  fluid  should  be  strained  while  hot  through  a  fine  sieve.  If  a 
jelly  is  to  be  made,'  the  broth  made  in  the  above  manner  should  be 
allowed  to  cool  in  an  earthen  jar  for  about  twelve  hours  in  the  ice-chest. 
The  resulting  jelly  can  be  used  in  full  strength  or  diluted  with  water. 
When  the  jelly  has  been  thoroughly  Cooled,  the  fat  can  be  partially  or 
entirely  removed  from  the  top. 

Mutton  Broth. — A  shoulder  of  lamb,  when  it  can  be  obtained, — 
otherwise  of  mutton, — weighing  from  five  to  seven  pounds,  is  treated  in 
the  same  way  as  is  the  fowl  for  the  preparation  of  chicken  broth. 

THIRD  NUTRITIVE  PERIOD. 

The  third  nutritive  period  we  have  arbitrarily  made  to  begin  at  about 
the  thirtieth  month  of  life. 

At  this  time  it  will  be  well  to  begin  to  accustom  the  child's  digestive 
functions  to  a  still  greater  variety  of  food.  In  summer  the  more  easily 
digestible  vegetables,  such  as  squash,  young  peas,  and  young  beans,  can 
be  given.  The  variety  of  fruits  can  also  be  increased  at  this  period,  but 
they  should  be  cooked.  The  principal  change  which  is  to  be  made  in  the 
diet  to  which  the  infant  has  been  accustomed  is  a  very  decided  increase  in 
the  proportion  of  the  proteid  element  of  its  food.  This  is  accomplished 
by  means  of  giving  the  child  meat.  The  quantity  of  meat  which  should 
be  given  towards  the  end  of  the  third  year  should  be  small  at  first,  and 
should  be  given  at  intervals  of  a  day  or  two.  Meat  as  a  regular  article 
of  diet  for  each  day  is  not,  as  a  rule,  required  until  the  child  is  between 
three  and  four  years  old.  The  kinds  of  meat  which  should  be  given  in 
this  early  period  of  childhood  are  chicken,  mutton-chop,  roast  beef,  and 
beefsteak.  These  meats  should  be  cut  into  small  pieces,  and  a  little  salt 
added  according  to  the  child's  taste.  It  is  well  during  the  third  year  to 
give  the  child  an  egg  on  one  day  and  meat  on  the  next. 

When  the  child  has  reached  the  age  of  five  or  six  years,  we  should 
allow  it  to  have  a  somewhat  more  varied  diet,  but  during  the  whole 
period  of  childhood  up  to  the  age  of  puberty  the  closest  attention  should 
be  given  to  the  regulation  of  the  kind  and  the  amount  of  food  to  be 
Ifiven  to  the  child,  and  any  deviations  from  the  rules  which  have  just 
been  laid  down  are  to  be  deprecated. 


DIVISION     III. 

GENERAL    PRINCIPLES    OF    EXAMINATION    AND 

TREATMENT. 


Method  of  examining  a  Child. — When  a  physician  is  cahed  to  see  a 
sick  child,  he  must,  if  possible,  ascertain  before  entering  the  nursery  what 
is  the  temperament  of  the  child  with  whom  he  will  have  to  deal,  and  by 
the  aid  of  this  information  regulate  the  manner  in  Avhich  he  approaches  it. 

An  infant  in  the  early  months  of  life  too  young  to  fear  a  stranger,  a 
child  of  quiet  phlegmatic  temperament,  or  one  that  is  too  sick  to  object  to 
being  handled,  can  be  examined  as  soon  as  it  is  seen,  with  the  regularity 
and  precision  which  one  would  employ  with  the  adult. 

It  is  an  entirely  different  task,  however,  when  one  is  called  upon  to 
examine  children  who  are  nervous,  excitable,  or  timid,  or  who  are  spoiled 
and  vicious.  In  dealing  with  the  first  and  more  difficult  class  of  these 
cases  much  deliberation  in  the  way  in  which  the  child  is  approached  is 
needed,  and  much  tact  in  speaking  to  it  is  required.  In  the  second,  the 
spoiled  and  vicious  class,  time  cannot  be  gained  by  delaying  the  examina- 
tion, and  the  sooner  it  is  made  with  firmness  and  persistence  the  less  try- 
ing it  will  be  for  the  child  and  for  the  mother.  As  a  rule,  the  more  the 
child  cries  and  resists  needlessly,  the  less  Hkely  is  it  to  have  any  disease 
of  serious  import. 

It  is  wise  at  first  to  make  the  child  think  that  no  notice  is  being  taken 
of  it.  It  is  w^ell  to  notice  its  toys,  and  to  appear  to  take  great  interest  in 
them  and  also  in  the  pictures  in  the  nursery.  The  child  very  soon  will 
become  accustomed  to  the  physician's  presence,  and  will  begin  to  take  the 
same  interest  in  him  that  he  seems  to  take  in  its  toys.  A  nervous,  timid 
child  will  often  from  this  point  of  the  examination  allow  itself  to  be  ex- 
amined without  further  trouble. 

The  pliysician,  ho\vever,  should  always  be  gentle  both  in  his  voice  and 
in  his  touch,  and  on  the  slightest  appearance  of  timidity,  or  manifestation 
of  a  desire  to  avoid  him,  he  should  at  once  stop  the  special  part  of  the 
examination  which  he  is  making,  and  appear  not  to  take  any  notice  of 
the  child. 

All  these  preliminaries  and  minute  details,  which  seemingly  delay 
the  examination,  in  fact  expedite  it,  since,  when  once  the  timid  child  is 
236 


GENERAL    PRINCIPLES   OF   EXAMINATION   AND   TREATMENT.         237 

thoroughly  frightened,  the  rest  of  the  examination  becomes  very  unsatis- 
factory, for  it  is  almost  cruel  in  cases  of  this  kind  to  attempt  to  force  an 
examination,  which  in  the  case  of  the  vicious  child  can  be  done  usually 
without  cruelty  and  without  hurting  the  feelings  of  the  mother. 

The  faculty  of  examining  the  child  when  it  is  crying  and  excited  with 
the  same  precision  as  when  it  is  quiescent,  though  perhaps  by  a  somewhat 
different  method,  should  be  acquired.  The  trained  hand  and  ear  can 
detect  an  abdominal  or  pleuritic  effusion  or  a  solidified  lung  almost  as 
well  when  the  child  is  screaming  as  when  it  is  perfectly  docile. 

This  is  an  accomplishment  which  should  be  mastered  at  once  by  every 
practitioner  who  expects  to  have  children  under  his  care.  In  fact,  if  this 
were  more  universally  understood,  we  should  hear  less  of  the  impossibility 
of  determining  what  is  the  matter  with  a  child  on  account  of  its  being 
fractious. 

As  the  physical  examination  of  a  child  is  more  difficult  than  that  of  an 
adult,  and  needs  to  be  made  more  quickly,  every  means  should  be  em- 
ployed which  \\"ill  tend  to  throw  light  on  the  final  result. 

History. — ^A  complete  history  of  the  case  is  very  valuable,  and  should 
be  obtained  from  the  mother  and  the  nurse,  preferably  before  seeing  the 
child,  for  in  this  way  the  physician  can  obviate  asking  many  questions  in 
its  presence,  a  procedure  which  frequently  fatigues  it  and  renders  it  more 
difficult  to  examine.  It  is  well  to  allow  the  mother  and  the  nurse  to  tell 
in  their  own  language  what  they  know  about  the  child  and  its  sickness. 
After  they  have  finished,  one  can  easily  systematize  the  history  of  the  case 
by  any  questions  which  one  may  wish  to  ask.  Although  the  history  given 
by  the  mother  and  the  nurse  is  usually  imperfect  and  disconnected,  yet 
it  is  very  likely  to  supply  certain  important  points  which  on  questioning 
might  easily  be  overlooked.  The  mother  and  the  nurse  are  so  constantly 
with  the  child  that  they  notice  all  the  slight  shades  of  difference  in  its 
condition  from  hour  to  hour,  a  knowledge  of  which  is  of  great  importance' 
in  obtaining  a  correct  appreciation  of  the  general  condition  of  the  child, 
whatever  the  disease  may  be. 

The  information  especially  to  be  elicited  is  in  regard  to  the  health  of 
the  parents,  whether  there  is  an  hereditary  tendency  in  the  family ; 
whether  the  mother  has  had  miscarriages  (in  reference  to  a  possible  syph- 
ilis) ;  whether  there  are  other  children,  and,  if  so,  the  state  of  their  health  ; 
if  any  have  died,  of  what  did  they  die ;  the  birth  weight  of  this  child ; 
was  it  nursed,  and,  if  so,  for  how  long ;  did  it  have  a  substitute  food,  and,  if 
so,  of  what  kind  ?  Did  it  gain  in  weight  regularly,  and  what  is  its  present 
weight?  At  what  age  did  it  cut  its  first  tooth,  and  how  many  has  it  noAv? 
At  what  age  did  it  sit,  and  stand,  and  walk  alone  ?  What  diseases  has  it 
had  ?  How  long  has  it  been  sick  ?  What  were  the  first  symptoms  ?  Its 
appetite  ?  Its  sleep  ?  Its  temper  ?  The  number  of  its  movements  in 
twenty-four  hours  ?  The  physician  should  personally  inspect  the  faeces, 
and  should,  if  possible,  obtain  and  examine  a  specimen  of  the  urine. 


238  PEDIATRICS. 

Having  now  systematized  in  his  own  mind  the  history  of  the  case,  the 
physician  on  entering  the  nursery  should  proceed  with  his  inspection  of 
the  child. 

Temperature. — It  is  so  important  to  ascertain  what  the  temperature 
of  the  child  is  that,  if  possible,  the  temperature  should  be  taken  before 
the  child  has  become  frightened  or  fractious.  The  place  for  taking  the 
temperature  should  be  in  the  axilla  or  rectum.  The  most  successful 
method  of  obtaining  it  is  to  explain  to  the  mother  and  nurse  exactly 
what  one  wishes  to  have  done.  They  should  be  directed  to  take  the 
thermometer  and  show  it  to  the  child  as  though  it  were  a  toy,  to  put  it 
under  the  child's  arm,  and  to  play  ^^ith  the  child  until  they  are  told  to 
remove  the  thermometer.  A  rectal  temperature  is  always  desirable  when 
it  can  be  obtained,  as  it  is  more  exact,  and  is  usually  at  least  one  degree 
higher  than  under  the  arm.  As  a  rule,  tlie  temperature  cannot  be  safely 
taken  in  the  mouth  in  young  children. 

Inspection. — One  of  the  most  valuable  means  of  making  a  diagnosis 
of  disease  in  children  is  the  careful  inspection  of  the  child  before  attempt- 
ing to  percuss  or  to  auscult  it.  In  fact,  when  children  are  irritable  and 
restless  the  inspection  becomes  of  the  utmost  importance,  and  an  eye 
which  has  been  trained  to  understand  the  different  aspects  of  disease  in 
children  readily  makes  the  diagnosis  in  many  cases  ^^dthout  further  assist- 
ance. A  rule  to  be  remembered,  and  one  which  will  be  found  of  great 
practical  value,  is,  if  possible,  to  have  the  child  entirely  undressed,  so  that 
we  may  see  the  whole  surface  of  the  skin  in  front  and  behind.  Not  only 
shall  we  thus  be  able  to  recognize  the  symptoms  attributable  to  a  simple 
irritation  of  the  skin,  whereas  otherwise  Ave  might  be  led  to  consider 
them  as  representing  a  more  general  and  constitutional  disturbance,  but 
the  skin  will  also  be  found  to  be  a  valuable  index  by  which  to  judge  of 
diseases  of  the  other  organs.  The  cyanosis  which  so  frequently  represents 
some  disturbance  in  the  heart  or  lung,  the  quick  respirations  of  either  a 
thoracic  or  an  abdominal  type,  a  sunken  or  a  distended  abdomen,  and  the 
position  of  the  child,  all  point  towards  symptoms  belonging  to  special  dis- 
eases. By  means  of  all  these  symptoms,  which  can  be  seen  at  a  glance, 
the  diagnosis  of  the  special  disease  can,  after  considerable  experience, 
usually  be  made  without  much  aid  from  other  sources. 

RESPmATioN. — Either  when  the  thermometer  is  under  the  child's  arm 
or  when  the  regular  inspection  is  begun,  the  rate  and  rhythm  of  the  res- 
piration can  be  determined.  Having  determined  the  temperature  and 
respiration,  if  all  that  is  necessary  about  the  child  when  it  is  quiescent 
has  been  seen,  the  physical  examination  should  next  be  made. 

Palpation. — Palpation  is  a  very  valuable  means  of  diagnosticating 
disease  in  children,  whether  it  be  of  the  abdomen  or  of  the  thorax.  It  is 
well  to  begin  A^ith  an  attempt  to  take  the  pulse.  Sometmies  this  can  be 
readily  accomplished.  At  other  times  it  is  impossDDle,  and,  as  a  rule,  we 
rely  less  on  the  rapidity  of  the  pulse  in  the  child  than  on  the  information 


GENERAL   PRINCIPLES   OF   EXAMINATION   AND   TREATMENT.         239 

which  is  received  from  the  temperature  and  respiration.  It  takes  so  little 
to  increase  the  rate  of  the  pulse  in  a  young  child  that  if  we  were  to 
judge  in  every  case  by  it  we  should  often  be  misled  in  our  diagnosis. 
What  we  wish  especially  to  learn  is  whether  there  is  a  slow  pulse  or 
whether  it  intermits.  This  we  can  usually  ascertain  by  keeping  our 
finger  for  a  few  seconds  on  the  child's  radial  artery.  When  we  have 
once  obtained  a  fair  idea  of  the  rate  and  rhythm  of  the  pulse  we  can 
proceed  with  the  remainder  of  our  examination  by  palpation. 

A  young  child's  thoracic  walls  are  so  thin,  and  vibration  is  so  pro- 
nounced in  them,  that  often  we  can  detect  what  process  is  going  on  in  the 
lung  by  merely  putting  our  hand  on  the  chest,  and  we  can  feel  in  a  chronic 
bronchitis  what  will  prove  on  auscultation  to  be  coarse  sonorous  rales.  We 
can  also  sometimes  feel  a  pleuritic  or  a  pericardial  friction-rub,  and  fre- 
quently a  roughening  of  one  of  the  valves  of  the  heart.  It  is  not  alto- 
gether impossible  in  certain  cases  to  distinguish  the  difference  presented 
to  the  hand  between  a  pleuritic  effusion  and  a  solidified  lung.  The  ex- 
amination of  the  abdomen,  even  when  the  child  is  crying,  can  be  ac- 
complished with  considerable  precision.  Waiting  until  the  child  stops 
crying  for  a  second  and  relaxes  its  abdominal  walls,  by  firm  but  gentle 
pressure  the  abdominal  walls  can  be  depressed  so  as  to  obtain  a  fair 
knowledge  of  whether  an  abdominal  tumor  is  present.  Fluid  in  the  ab- 
dominal cavity  can  also  readily  be  detected  by  palpation. 

A  rectal  examination  is  often  important  in  infants  and  young  children. 
It  can  readily  be  made  without  hurting  the  child,  and  the  finger  is  able 
to  reach  much  farther  proportionately  into  the  child's  pelvis  than  into 
that  of  the  adult,  and  very  much  more  can  be  learned  by  this  method 
than  in  adult  cases.  An  invagination  or  an  appendicitis  can  be  diagnosti- 
cated by  the  combined  examination  through  the  rectum  and  by  external 
pressure  when  external  palpation  alone  has  failed  to  give  evidence  of 
disease. 

In  the  infant  the  head  should  be  carefully  examined  in  reference  to 
the  fontanelles.  Measurements  should  be  taken  of  the  head  and  of  the 
thorax. 

At  this  stage  of  the  examination  we  shall  have  determined  almost 
always  what  disease  is  affecting  the  child,  but  every  known  method  should, 
of  course,  be  made  use  of  for  verifying  the  diagnosis.  We  should,  there- 
fore, endeavor  to  percuss  and  auscult  the  child,  but  in  a  somewhat  dif- 
erent  way  from  that  which  would  naturally  be  employed  in  the  adult. 
The  louder  the  child  cries,  the  easier  is  it  to  obtain  evidence,  through 
vocal  fremitus,  of  the  nature  of  the  disturbance  in  the  chest. 

Percussion. — Even  when  the  child  is  crying  and  resisting,  percussion 
may  be  of  the  greatest  importance.  Light  percussion,  as  a  rule,  is  prefer- 
able to  the  deeper  and  heavier  percussion.  The  chest  walls  are  so  reso- 
nant that  deep  percussion  rather  masks  the  process  which  is  directly  under 
the  finger  by  bringing  out  sounds  from  all  parts  of  the  chest.     Direct  per- 


240  PEDIATRICS. 

cussion  with  the  finger  is  preferable  to  the  use  of  any  instrument,  as  iu 
this  Avay  both  palpation  and  percussion  may  be  combined.  Palpatory  per- 
cussion in  my  hands  has  always  proved  exceedingly  valuable  for  purposes 
of  diagnosis.  A  few  light  taps  over  the  normal  boundaries  of  the  heart 
and  lung  will  give  much  information,  even  though  it  may  be  impossible 
to  obtain  a  more  extended  percussion  of  the  chest.  If  the  child  is  crying, 
one  should  Avatch  until  it  takes  its  breath ;  just  as  it  inspires  it  necessaril\- 
stops  crying,  and  at  that  moment  a  perfectly  clear  percussion  note  can  be 
obtained. 

Care  should  be  taken  not  to  make  the  physical  examination  too  pro- 
tracted. Rapidity,  both  hi  palpation  and  in  percussion,  is  very  important, 
and  a  young  child  should  be  examined  with  much  greater  rapidity  than  is 
usual  or  necessary  in  the  case  of  an  adult.  Much  more  information  \vill 
be  obtained  in  this  way  tlian  if  the  child  is  wearied  by  continual  efforts  to 
make  sure  that  no  mistake  lias  been  made. 

The  sounds  which  can  be  elicited  frojn  a  young  child's  chest  are  so 
varied  that  it  is  more  difficult  to  differentiate  them  than  in  the  adult.  If 
one  hesitates  and  doubts  one  Avill  not  arrive  at  as  correct  a  result  in  the 
examination  as  Avhen  the  mind  is  trained  to  grasp  at  once  the  salient  points 
in  the  special  physical  examination,  and  to  depend  somewhat  more  on  the 
first  idea  which  is  formed  than  would  be  wise  in  the  older  cases. 

Auscultation. — We  have  noticed  that  children  are  much  more  sensitive 
to  the  feeling  of  the  stethoscope  than  are  adults.  In  many  cases  they 
shrink  from  it  as  though  it  hurt  them,  even  when  they  have  not  been 
frightened  by  the  previous  part  of  the  examination  witli  palpation  and  per- 
cussion. It  is,  therefore,  exceedingly  important  to  make  the  examination 
as  pleasant  to  the  child  as  possD^le.  A  rubber  cup  applied  to  the  end  of 
the  stethoscope  serves  this  purpose  well.  The  feeling  of  the  soft  rubber 
is  pleasant  to  the  child,  and  it  conveys  the  sound  with  almost  as  much 
clearness  as  does  the  hard  rubber  end  of  the  stethoscope.  The  stetho- 
scope should  have  flexible  rubber  arms  so  as  to  follow  easily  the  motions 
of  the  child,  and  its  bell  should  be  of  such  small  caliber  that  it  can  easily 
be  introduced  between  the  ribs  of  even  a  young  child. 

In  like  manner  a  phonendoscope  with  a  small  disk,  such  as  is  repre- 
sented  in  Fig.  55  is  valuable  where  the  sounds  of  the  lungs  or  heart  are 
very  feeble,  or  when  it  is  found  preferable  to  examine  \vithout  having  all 
the  clothes  removed. 

It  is,  however,  often  of  great  aid  in  the  proper  appreciation  of  the 
sounds  which  are  heard  with  the  stethoscope  in  infants  and  in  young  chil- 
dren, especially  when  they  are  crying,  to  use  a  stethoscope  which  does  not 
convey  the  sound  so  clearly  and  intensely  as  do  others.  We  can  often  in 
this  way  differentiate  a  soft  cardiac  murmur  which  if  a  more  delicate  in- 
strument were  used  would  be  entirely  obscured  by  the  loud  sounds  coming 
from  the  trachea  and  bronchi  of  a  crying  or  screaming  child.  We  can, 
also,  often  distinguish  the  fine  rales  of  a  broncho-pneumonia  in  contradis- 


GENERAL    PRINCIPLES   OF    EXAMINATION   AND   TREATMENT. 


241 


tinction  to  the  loud  coarse  rS,les  which  tend  to  obscure  the  other  sounds 
in  the  chest. 

Examination  of  the  Throat. — The  examination  of  the  throat  should 
be  left  until  we  have  practically  finished  with  the  general  examination  of 
the  child,  because,  as  a  rule,  it  is  the  procedure  of  all  others  which  irri- 
tates it,  and  after  we  have  once  attempted  to  examine  the  throat  we  shall 


Fig.  55. 


Fig.  56. 


Phonendoscope.    Reduced  twotifths. 


Tongue  depressor.    Reduced  56  per  cent. 


seldom  be  forgiven  by  the  child  at  that  special  visit.  Some  children  will 
allow  you  to  look  into  their  throats  without  being  at  all  disturbed.  As  a 
rule,  however,  it  frightens  them,  and  we  should  use  the  most  gentle  and 
rapid  methods  for  accomplishing  our  purpose.  We  must  not  expect  to  be 
able  to  sit  down  in  front  of  the  child  and  examine  its  throat  for  some 
minutes,  as  is  possible  with  adults.  We  must  adopt  some  definite  method 
by  which  we  can  control  the  child  and  catch  a  glimpse  of  the  mouth, 
tongue,  and  pharynx.  The  more  quickly  we  do  this,  the  less  it  friglitens 
the  child,  and  it  is  important  that  we  should  not  make  extensive  prepara- 
tions which  it  will  notice  and  which  will  indicate  what  we  are  going  to  do. 
The  mothers  are  often  much  disturbed  by  seeing  the  child  first  frightened 
with  the  idea  that  it  is  going  to  have  a  spoon  put  in  its  mouth,  and  then, 
while  screaming  and  crying,  forced  to  the  window  and  compelled  to  open 


242  PEDIATRICS. 

its  mouth.  It  is  far  better  under  all  circumstances  to  tell  the  mother  and 
the  nurse  what  to  do,  and  for  us  not  to  go  near  the  child  until  they  are  en- 
tirely prepared  to  control  its  limbs  and  are  holding  it  in  a  position  in  which 
it  is  practically  helpless.  It  frightens  the  child  much  less  to  have  it  sit  in 
the  nurse's  lap  with  its  face  to  the  window  than  to  examine  it  on  its  back. 

The  nurse  should  hold  the  child  firmly  against  her  chest,  so  that  it 
cannot  move  its  arms  or  legs  or  slip  from  her  lap.  The  physician  should 
control  the  child's  head  with  one  hand  while  with  the  other  he  gently  in- 
troduces the  handle  of  a  spoon  into  the  mouth,  passing  it  back  until  it 
touches  the  soft  palate,  when  the  child  will  gag,  and  a  quick  glance  can  be 
obtained  of  the  tonsils  and  pharynx. 

We  prefer  to  use  a  spoon  for  examining  the  throat,  because  in  every 
household  one  may  be  easily  obtained,  and  it  obviates  the  use  of  the 
same  instrument  in  a  number  of  mouths,  which  is  something  to  be  con- 
sidered in  children,  in  whom  infection  by  the  mouth  is  so  common.  Of 
course,  for  those  who  prefer  to  use  the  usual  tongue-depressor  the  danger 
is  reduced  to  a  minimum  if  a  careful  disinfection  of  the  instrument  is  made 
after  it  is  used ;  but  in  the  case  of  infants,  who  should  also  be  examined 
in  an  upright  position,  the  spoon  is  decidedly  preferable,  because  the  neck 
of  the  infant  is  so  short  that  its  chin  is  in  close  proximity  to  its  chest,  and 
the  handle  of  the  tongue-depressor  interferes  with  the  proper  downward 
pressure  of  the  instrument.  The  spoon-handle,  on  the  other  hand,  is 
exactly  the  shape  which  is  best  adapted  to  the  infant's  mouth  and  tongue, 
and  the  spoon,  being  comparatively  straight,  does  not  encroach  upon  the 
thorax  when  the  downward  pressure  is  made. 

Fig.  56  represents  a  tongue-depressor  devised  by  Dr.  Henry  Chapin, 
of  New  York,  and  is  remarkably  well  suited  for  the  examination  of  the 
infant's  throat,  as  the  curve  is  adapted  to  that  of  the  tongue. 

The  Throat. — The  throat  of  the  child  may  often  be  affected,  and  be  the 
only  source  of  the  symptoms,  although  these  symptoms  may  not  be  what 
one  would  expect  to  find  associated  with  a  lesion  in  this  region.  Young 
^--children  are  so  apt  not  to  complain  of  their  throat,  and  to  show  merely 
signs  of  general  constitutional  disturbance,  that  the  physician  is  ybtj  likely  to 
be  misled  and  to  overlook  the  real  seat  of  the  disease  unless  he  makes  it  a 
rule  always  to  examine  the  throat  at  his  first  visit  and  in  all  obscure  cases. 

Inspection  of  the  Mouth. — It  is  well  when  the  physician  is  examining 
the  throat  of  an  infant  in  the  first  two  years  of  its  life,  and  even  later  if 
there  are  any  symptoms  which  point  towards  the  mouth,  to  examine  the 
gums  carefully.  The  hands  should  be  carefully  washed  before  intro- 
ducing the  fingers  into  the  mouth.  This  is  in  accordance  with  the 
common  rules  of  cleanliness,  and  also  is  required  in  order  that  the  intro- 
duction of  pathogenic  organisms  into  the  infant's  mouth  should  be  avoided.  ' 
In  examining  the  gums  we  judge  whether  they  are  swollen  or  reddened, 
dry,  moist,  or  hotter  than  normal,  and  also  whether  there  is  a  condition 
of  the  gums  which  indicates  the  use  of  the  lancet. 


GENERAL  PRINCIPLES    OF   EXAMINATION   AND   TREATMENT.         243 

Examination  of  the  Ears. — One  of  the  most  important  means  of  rightly 
interpreting  the  symptoms  of  restlessness,  of  evident  pain,  of  heightened 
temperature,  of  undue  somnolence,  as  well  as  a  great  many  other  symp- 
toms, is  the  examination  of  the  ears  of  infants  and  of  young  children.  A 
slight  irritation  in  the  throat  may  at  times  cause  a  congestion  in  the  vessels 
of  the  membrana  tympani  which  may  produce  all  these  symptoms. 

It  is,  therefore,  very  important,  unless  one  is  sure  that  the  symptoms  do 
not  arise  from  some  condition  in  the  ear,  that  one  should  examine  the 
ears  at  some  time  during  the  visit,  choosing  that  time  which  seems  most 
favorable  in  the  especial  case.  A  thorough  knowledge  of  the  possible 
symptoms  which  may  arise  from  the  ear  is  of  the  very  greatest  impor- 
tance for  the  general  practitioner  to  jDossess. 

Lumbar  Puncture. — Paracentesis  of  the  vertebral  canal  is  of  great  aid 
in  certain  cases.  This  procedure  is  employed  for  diagnosis  in  obscure 
cerebral  disease,  and  enables  us  to  determine,  first,  whether  a  meningitis 
is  present,  and  second,  whether  it  is  a  form  of  tubercular,  non-tubercular, 
or  cerebro-spinal  meningitis. 

RoNTGEN  Light. — The  X-ray  has  been  used  more  extensively  and  suc- 
cessfully in  surgical  cases  than  in  medical,  and  its  use  for  medical  cases  in 
children  has  so  far  been  rather  limited.  As  in  diseases  of  the  heart  and 
lungs  it  is  not  only  their  size  but  their  movements  which  we  wish  to 
observe,  the  fluoroscope  is  better  adapted  for  detecting  pathological  con- 
ditions. Examination  with  this  instrument  can  also  be  made  more 
quickly  than  with  the  radiograph,  which  requires  more  time  to  develop, 
but  gives  more  details  of  those  organs  which  are  at  rest.  An  example 
of  the  extent  to  which  radiography  is  applicable  for  showing  the  outlines 
of  the  organs,  even  when  they  are  moving,  can  be  seen  in  Plate  IV.,  facing 
page  244,  which  represents  the  thorax  and  abdomen,  with  their  contents, 
of  a  child  of  six  months,  and  in  Plates  XIII.  and  XV.,  pages  717  and  884. 

It  is  now  claimed  that  mth  the  fluoroscope  thoracic  and  pericardial 
effusions,  even  when  small,  can  be  detected ;  also  that  a  central  pneu- 
monia can  be  recognized  before  there  are  any  signs  on  auscultation  and 
percussion,  and  that  the  area  of  consolidation  of  a  pulmonary  tubercu- 
losis can  be  diagnosticated  by  the  diseased  area  of  the  lung  appearing 
darker  than-  normal,  and  by  the  restriction  of  the  excursion  of  the  dia- 
phragm in  quiet  breathing  and  in  full  inspiration.  An  enlarged  heart  or 
a  transposed  heart  can  also  be  detected  with  the  fluoroscope.  The  X-ray 
photograph  reveals  changes  in  the  bones,  such  as  occur  in  rhachitis  (Plate 
v.,  facing  page  324);  in  tuberculosis  (Plate  VI.,  facing  page  504);  in  osteo- 
myelitis (Plate  VI.,  facing  page  504)*;  in  syphilis  (Plate  VII.,  facing  page 
528) ;  and  also  changes  in  the  various  abdominal  organs.  Radiography 
is  therefore  probably  destined  to  become  a  very  important  aid  in  our 
diagnosis  in  the  diseases  of  children,  and  should  always,  if  possible,  be 
used  in  obscure  cases,  such  as  we  are  continually  meeting  with,  especially 
in  the  lung  in  which  a  central  pneumonia  may  be  masked  for  many  days, 


244  PEDIATRICS. 

and  yet  the  child  be  so  ill  as  to  cause  the  most  serious  apprehensions  as 
to  diagnosis  and  prognosis. 

Treatment  in  General. — The  treatment  of  infants  and  children  con- 
sists largely  in  the  administration  of  a  food  adapted  to  the  condition  of 
the  child,  and  in  gradually  changing  from  a  weak  food  to  a  strong  one,  or 
vice  versa,  according  to  the  especial  indications  in  the  disease  as  it  runs 
its  course.  Of  great  importance  also  is  the  regulation  of  the  temperafurc 
and  the  purity  of  the  air  in  the  sick-room.  In  many  cases,  especially  in 
the  first  year  of  life,  a  change  from  one  room  to  another  several  times 
during  the  day  is  advanteigeous,  and  the  room  should  be  as  large  as  possi- 
ble. The  application  of  cold  and  heat  by  sponging  and  baths,  and  the 
technicjue  of  gavagc,  lavage,  and  intestinal  irrigation,  will  be  spoken  of  in 
describing  the  treatment  of  the  various  diseases  in  which  they  are  indi- 
cated. 

Stimulants,  if  used  with  good  judgment  and  given  as  described  in  the 
treatment  of  the  various  diseases,  are  very  valuable,  and  are  called  for 
not  only  in  cases  of  sudden  collapse,  in  which  their  administration  ]Dy  sub- 
cutaneous injection  is  indicated,  but  whenever  there  is  depression  with  a 
Aveak  or  intermittent  pulse,  as  in  diphtheria,  at  times  in  typhoid  fever, 
and  also  where  there  is  a  sudden  fall  in  temperature,  as  is  somelimes  seen 
at  the  crisis  of  a  pneumonia.  The  amount  of  the  stimulant  for  tiic  espe- 
cial age  cannot  be  given,  as  it  depends  entirely  on  the  disease  and  the 
condition  of  the  especial  patient.  The  form  of  stimulant  which  is  borne 
best  by  young  children  is  brandy  or  whiskey.  The  contra-indications  for 
stimulants  are  found  in  those  cases  in  which  the  child  has  a  hot,  dry  skin, 
flushed  face,  and  a  full,  regular,  and  tense  pulse.  Great  caution  should 
be  used  in'  the  administration  of  stimulants,  as  there  is  no  doubt  that 
they  are  given  with  but  little  judgment  in  many  cases,  and  that  to  obtain 
the  best  results  they  should  be  reserved  for  cases  in  which  they  are  clearly 
indicated.  They  should  be  giverl  in  rather  small  doses,  the  larger  doses 
■being  reserved  for  special  conditions.  As  a  rule,  the  average  practitioner 
ogives  much  larger  doses  of  stimulants  than  are  needed. 

Especial  attention  should  be  drawn  to  the  fact  that  the  younger  the 
infant  the  greater  is  the  importance  of  keeping  the  nasal  passages  clear, 
irrespective  of  the  disease.  The  infant  responds  much  more  quickly  to 
treatment  if  its  vitality  is  not  lowered  by  its  efforts  to  breathe  through  its 
mouth  rather  than  through  the  natural  passages.  A  spray  of  oil  is  the 
treatment  in  young  children  for  occluded  nares.  Nasal  irrigation  is  de- 
scribed under  the  treatment  of  diphtheria  on  ):)age  473  ;  cuemafa  on  ])age 
830,  and  atomization  of  the  throat  and  larynx  on  page  G5o. 

An  important  fact  to  remember  in  the  treatment  of  infants  and  young 
children  is  that  drugs  play  a  very  insignificant  part  in  the  actual  cure  of 
diseases.  According  to  our  observation,  numbers  of  children  are  need- 
lessly treated  by  drugs,  and  often,  so  far  as  we  can  see,  this  time-honored 
means  of  satisfying  parental  prejudices  often  prolongs  llie  synijjlnms  of 


PLATE    IV. 


Iiiiaut,  b  months  old.  TaKen  under  chloroform  from  behind.  Stomach  and  larsre  intestine  dis- 
tended with  gas.  1,  right  lung;  2,  left  lung;  3,  heart;  4,  liver;  5,  stomach;  6,  left  kidney  7  ri-ht 
kidney  ;  S,  ascending  colon  ;  9,  descending  colon  ;  10,  probably  the  head  of  the  pancreas  '    '      ° 


GEXERAT.    nUXriPLES    OF    EXAMINATION    AND    TREATMENT.         245 

a  disease  which,  self-Umitecl,  has  run  its  course.  We  do  not  for  a  moment 
question  the  direct  benefit  obtained  from  quinine  in  malaria  and  mercury 
in  syphilis,  the  salicylates  in  rheumatic  fever,  and  from  the  relief  of  symp- 
toms, especially  those  of  pain  and  functional  inactivity  of  the  heart,  kidneys 
and  organs  of  digestion,  by  various  popular  and  efficient  remedies  :  it  is  the 
promiscuous  use  of  drugs  in  every  case  of  sickness  to  which  we  are  espe- 
cially opposed,  for  in  many  cases  the  child  will  recover  with  equal  or  even 
greater  rapidity  without  them. 

Instances  probably  arise  in  the  practice  of  every  physician  in  which  he 
feels  that  the  drugs  which  have  been  given  have  either  directly  harmed  the 
child  or,  by  disturbing  its  digestion  and  thus  interfering  with  its  nutrition, 
have  indirectly  produced  more  serious  symptoms  than  those  presented  by 
the  original  disease.  The  greatest  caution  should  be  employed  when  drugs 
are  used  with  young  children,  and  there  should  be  a  thorough  understand- 
ing of  their  action  during  the  various  periods  of  development.  The  well- 
known  susceptibility  of  children  to  the  action  of  opium  and  its  alkaloids 
should  make  us  careful  to  begin  with  minimum  doses  when  it  is  necessary 
to  use  this  drug.  In  like  manner,  although  it  is  traditional  that  children 
have  a  great  tolerance  for  belladonna  and  arsenic,  we  must  allow  that  an 
overdose  of  the  former,  although  not  usually  fatal,  may  certainly  produce 
most  alarming  symptoms,  while  the  administration  of  the  latter  as  we  have 
seen  it  given  in  the  treatment  of  chorea  has  in  a  number  of  cases  produced 
a  multiple  neuritis. 

The  treatment  of  diseases  by  special  drugs  because  these  drugs  have 
been  given  in  the  past,  because  their  administration  has  apparently  done  no 
harm,  or  because  no  new  or  better  remedy  has  been  found,  rests  upon  a 
lack  of  comprehension  of  what  treatment  really  means. 

The  custom  of  combining  many  drugs  in  one  prescription  is  fallacious, 
and  should  be  discountenanced,  especially  when  infants  and  young  chil- 
dren are  being  treated.  A  single  drug  given  in  the  smallest  dose  which  will 
accomplish  its  purpose,  and  in  the  most  agreeable  form  which  is  compat- 
ible with  the  function  of  digestion,  will  produce  the  best  results  in  any  given 
disease. 

The  delicate  skin  of  infants  and  young  children  is  peculiarly  sensitive 
to  reflex  disturbances  caused  by  drugs  in  the  gastro-enteric  tract,  and  there- 
fore we  must  be  careful  not  to  mistake  the  appearances  produced  by  such 
reflex  irritation  for  the  various  lesions  of  the  skin  which  may  occur  in  a 
specific  disease.  Thus,  the  similarity  of  the  efflorescence  produced  by 
belladonna  to  that  accompanying  scarlet  fever  is  striking.  Almost  any 
drug,  as  well  as  certain  articles  of  diet,  may  in  some  individuals  produce 
forms  of  papular  erythema,  resembling  very  closely  some  of  the  dermal 
lesions  of  syphilis.  It  is  therefore  wise  to  avoid  these  possible  disturb- 
ances of  nutrition  by  giving  drugs  only  when  they  are  actually  known  to 
be  necessary,  and  by  omitting  them  as  soon  as  possible. 

It  has  always  seemed  to    us  irrational  to  prescribe  syrups  as  a  men- 


246  PEDIATRICS. 

struum  for  the  administration  of  drugs  to  children.  Their  well-known 
tendency  to  fermentation  is  sufficient  to  stamp  them  as  unfit  for  the  treat- 
ment of  a  period  of  life  when  the  undeveloped  condition  of  the  digestive 
function  indicates  the  vital  importance  of  protecting  this  function  in  every 
way. 

Each  case  must  be  treated  according  to  its  special  pathological  lesion  or 
specific  micro-organism.  As  year  by  year  we  are  discovering  the  organ- 
isms which  cause  special  diseases,  so  the  treatment  of  the  future  will  be  the 
actual  destruction  and  speedy  elimination  of  these  organisms  while  sup- 
porting the  strength  until  such  elimination  has  been  accomplished.  When 
no  known  organisms  exist,  the  treatment  should  be  if  possible  to  remove 
the  cause,  and  to  support  the  vitality  until  natural  processes  have  healed 
the  special  lesion,  produced  either  by  exposure  or  by  trauma. 

Prophylaxis. — At  no  period  of  life  is  the  prophylaxis  of  disease  so 
important  and  its  results  so  brilliant  as  in  infancy  and  early  childhood. 
When  physicians  have  sufficiently  recognized  the  fact  that  disease  in  young 
children  results  in  the  vast  majority  of  cases  from  a  disregard  of  the  laws 
of  hygiene  and  of  rational  methods  of  feeding,  they  will  so  impress  upon 
the  laity  the  true  meaning  of  infantile  prophylaxis  that  the  mortality  rate 
will  be  greatly  reduced. 


DIVISION  IV. 

PREMATURE    INFANTS. 


A  PREMATURE  infant  is  one  which  is  born  prior  to  the  usual  two  hun- 
dred and  eighty  days  which  represent  the  normal  duration  of  intra- 
uterine life. 

Very  few  cases  are  reported,  and  none  of  them  appear  to  be  abso- 
lutely authentic,  in  which  an  infant  has  survived  which  was  born  much 
before  the  twenty-seventh  or  twenty-eighth  week  of  intra-uterine  life. 
The  premature  infant  in  its  intra-uterine  development  is  unprepared  to 
meet  the  conditions  of  extra-uterine  life,  and  often  dies  within  a  few  days, 
and  usually  within  a  few  hours.  Home's  case,  which  was  said  to  have 
been  born  in  the  eighteenth  week,  and  measured  eight  inches,  Avas  alive 
and  in  good  health  at  nine  years.    This  case  is  unique  in  medical  literature. 

DETERMINATION  OP  AGE. — A  sufficient  number  of  careful  in- 
vestigations regarding  the  characteristic  appearances  and  the  development 
of  the  foetus  during  the  last  four  months  of  intra-uterine  life  has  not  yet 
been  made  and  recorded  to  enable  us  to  state  definitely  what  age  the 
infant  represents  when  it  is  born.  The  few  facts  which  we  possess  con- 
cerning this  subject  must,  however,  be  made  use  of,  and,  though  not  ab- 
solutely correct,  are  sufficiently  so  to  be  of  great  value  to  us  in  our  man- 
agement of  these  cases.  One  reason  for  the  difficulty  which  arises  in  every 
case  in  determining  the  age  of  the  foetus  is  that  the  conditions  which 
influence  its  growth  during  intra-uterine  life  are  very  varied.  The  health 
of  the  mother  and  her  hygienic  surroundings,  together  with  the  influence 
of  heredity  on  the  size  of  her  offspring,  present  good  reasons  for  decided 
variations  in  the  growth  of  the  foetus  in  difl'erent  cases  at  the  same  period 
of  intra-uterine  life. 

If  the  infant  is  living  when  it  is  born,  we  should  at  once  carry  out  the 
rules  for  preserving  its  life  which  have  proved  to  be  best  in  the  case  of  any 
infant  born  prematurely.  These  rules  should  be  insisted  on  even  if  the 
infant  has  been  born  at  a  much  earlier  stage  of  development  than  is,  ac- 
cording to  our  present  ideas,  compatible  with  its  viability.  This  is  neces- 
sary, because  so  many  errors  in  our  calculation  as  to  when  the  impregna- 
tion took  place  are  liable  to  arise,  and  also  because  a  foetus  may  have 
arrived  at  a  period  of  intra-uterine  development  which  is  perfectly  com- 
patible Avith  life,  and  yet  from  its  small  weight  and  general  characteristics 

247 


248  I^KDIATIUCS. 

have  the  appearance  of  one  whose  development  is  incompatible.  What- 
ever advances  we  may  make  in  the  future  in  preserving  the  lives  of  pre- 
mature infants  born  at  an  earlier  date  than  is  supposed  to  be  compatible 
with  life, — namely,  from  the  twenty-fourth  to  the  twenty-eighth  week, — 
it  would  hardly  be  practical  at  this  time  to  discuss  the  treatment  of  infants 
born  before  the  twenty-fourth  week. 

At  Twenty-four  Weeks. — A  fcetus  born  at  about  the  twenty-fourth 
week  of  intra-uterine  life  usually  breathes  feebly,  and  dies  in  the  course  of 
a  few  hours,  apparently  from  an  inability  to  accommodate  itself  to  condi- 
tions for  w^hich  it  is  not  prepared.  At  this  stage  of  development  it  may 
still  have  fine  hair  (lanugo)  over  the  whole  of  its  body,  but  it  is  often  the 
case  that  this  hair,  commonly  found  from  the  sixteenth  to  the  twentieth 
week  has  disappeared.  At  this  age  it  still  has  very  little  deposition  of 
fat  in  the  subcutaneous  cellular  tissue,  and  it  has  a  decidedly  emaciated 
appearance.  In  other  respects,  except  in  size,  it  does  not  differ  very 
much  in  its  appearance  from  the  foetus  of  some  weeks'  later  development. 
Its  eyelids  have  separated,  though  it  is  so  feeble  that,  as  a  rule,  it  cannot 
open  and  shut  them. 

The  estimation  of  the  length  of  the  foetus  is  difficult  to  make,  and,  on 
the  whole,  unsatisfactory  and  inexact.  These  measurements,  in  all  prob- 
ability, differ  very  much  when  made  by  different  investigators,  owing,  as 
Minot  has  pointed  out,  to  the  many  changes  in  the  curvature  of  the  longi- 
tudinal axis  of  the  human  embryo,  which  make  it  impracticable  to  employ 
any  one  system  of  measurement  in  obtaining  comparable  results  for  all 
ages.  Hecker's  figures,  however,  are  probably  as  reliable  as  any  we  know 
of.  According  to  this  author,  at  about  the  twenty-fourth  week  the  foetus 
measures  28  to  34  cm.  (11  i  to  13 J  inches).  Its  weight,  according  to 
Lusk,  is  about  690  grammes  (23  ounces). 

At  Twenty-eight  Weeks. — By  the  time  the  foetus  has  reached  the 
twenty-eighth  to  the  twenty-ninth  week  of  intra-uterine  existence  its  con- 
dition, so  far  as  its  development  is  concerned,  is  such  that  there  is  no 
necessary  contra-indication  to  its  living  if  it  happens  to  be  born  at  this 
time.  It  has  been  stated  that  an  infant  born  prematurely  at  the  twenty- 
eighth  week  is  more  likely  to  live  than  one  which  is  born  at  the  thirty- 
second  week  of  intra-uterine  life,  and  that  this  has  been  proved  by  sta- 
tistics. If  true,  the  reason  for  this,  we  believe,  is  because  much  greater 
care  is  taken  of  the  former  than  of  the  latter.  It  is  reasonable  to  believe 
that  an  earlier  stage  of  intra-uterine  development  is  less  likely  to  insure 
continuance  of  life  after  premature  birth  than  a  later  stage,  provided  the 
same  precautions  are  taken  in  each  case. 

Hecker's  and  Lusk's  figures,  in  a  general  Avay,  state  that  when  the 
foetus  is  born  at  about  the  twenty-eighth  to  the  twenty-ninth  week  it  meas- 
ures from  35  to  38  cm.  (about  13|  to  15  inches)  and  weighs  about  1170 
grammes  (39  ounces).  The  skin  is  still  wrinkled,  is  of  a  dull  red  color, 
is  covered  with  vernix  caseosa,  and  there  is  very  little  deposition  of  sub- 


PREMATURE    INFANTS.  249 

cutaneous  fat.  The  infant  can  move  its  limbs  slightly,  cries  feebly,  and 
often  dies  in  a  few  hours  or  days. 

At  Thirty-two  Weeks. — Again,  using  Hecker's  and  Lusk's  figures  for 
the  thirty-second,  thirty-sixth,  and  thirty-eighth  weeks,  at  about  the  thirty- 
second  week  of  intra-uterine  life  the  foetus  measures  from  39  to  41  cm. 
(about  15|  to  161^  inches)  and  weighs  about  1560  grammes  (52  ounces). 
The  hair  of  the  head  by  tliis  time  has  increased  in  tliickness,  and  tlie 
lanugo,  which  in  many  cases  is  pronounced  from  the  twenty-eighth  to  the 
thirty-second  week,  has  either  begun  to  disappear  or  has  entirely  disap- 
peared from  the  face.  Tlie  nails,  which  between  the  tAventy-eightli  and 
thirty-second  weeks  are  often  not  well  developed,  now  present  a  normal 
appearance,  though  they  frequently  do  not  cfuite  reach  the  tips  of  the  fin- 
gers. At  this  age,  also,  in  boys,  it  is  often  possible  to  feel  the  testicle  in 
the  scrotum.  There  is  usually,  also,  in  a  healthy  f(jetus,  considerable  depo- 
sition of  subcutaneous  fat,  and  the  senile  aspect  of  tlie  earlier  periods  of 
intra-uterine  life  is  much  lessened. 

At  THmTY-six  Weeks. — At  about  the  thirty-sixth  week  the  length  of 
the  fretus  is  from  42  to  44  cm.  (about  16|-  to  17|  inches)  and  its  av eight  is 
about  1920  grammes  (64  ounces).  The  lanugo  has  usually  at  this  period 
disappeared,  and  the  infant,  although  less  energetic  than  at  full  term,  is 
decidedly  stronger  than  in  the  previous  periods  Avhich  have  been  men- 
tioned. It  sleeps  a  great  deal,  and  is  still  in  a  condition  to  die  easily  un- 
less carefully  looked  after. 

At  TnmTY-EiGHT  Weeks. — At  about  the  thirty-eighth  week  of  intra- 
uterine life  the  infant  measures  about  45  to  47  cm.  (about  17|-  to  18| 
inches)  and  weighs  about  2310  grammes  (77  ounces). 

NORMAL  DEVELOPMENT. — There  have  been  so  few  observations 
recorded  of  the  development  of  the  various  parts  of  the  foetus  in  the  latter 
months  of  intra-uterine  life  that  we  are  not  prepared  to  describe  systemati- 
cally the  development  of  the  premature  infant  as  we  have  already  done 
that  of  the  infant  at  term.  There  are,  however,  certain  facts  which  we 
have  observed  and  others  which  have  been  recorded. 

Head,  Thorax,  and  Abdomen. — All  those  anatomical  conditions  which 
have  been  emphasized  in  describing  the  infant  at  term  as  being  especially 
prominent  are  still  more  marked  in  the  premature  infant.  Thus,  the  head 
is  large  in  comparison  with  the  thorax,  and  the  abdomen  is  in  almost 
every  case  much  distended  in  premature  infants,  owing  to  the  large  pro- 
portionate size  of  the  liver.  This  distention  of  the  abdomen  lasts  for 
many  weeks,  and  even  months,  and  its  gradual  return  to  the  normal  size 
and  appearance  is  one  of  the  signs  that  the  infant  is  doing  well  and  is 
gradually  acquiring  the  normal  anatomical  development  of  the  infant  born 
at  term. 

Skin. — The  various  changes  in  the  color  of  the  skin,  already  described 
as  represented  by  erythema  neonatorum  and  icterus  neonatorum,  we  have 
noticed  to  occur  in  the  premature  infant  ;.s  they  do  in  the  infant  at  term. 


250 


PEDIATRICS. 


The  following  figures  represent  the  foetal  stomach  at  four  and  one-half,  seven  and 
one-half,    and  eight  months.     Fig.    57    represents  the  stomach  at  four  and  one-half 


Fig. 


Fig.  58. 


FcEtal  stomach  (natural  Foetal  stomach  (natural  size),  7>^  months  old.  Weight 

size),  4,i2  months  old.  of  foetus,  1920  grammes.    Gastric  capacity,  IS  c.c. 

months,  and  is  interesting  merely  as  showing  the  relatively  advanced  development  cf 
the  lesser  and  greater  curv^atures  at  this  age,  as  well  as  the  rapid  growth  which  takes 
place  between  the  fourth  and  the  seventh  month. 

Fig.  59. 


Foetal  stomach  (natural  size),  8  months  old.    Weight  of  fcEtus,  1230  grammes.    Gastric  capacity,  22  c.c. 


The  next  stomach  (Fig.  58)  was  taken  from  an  infant  born  prematurely  at  about  the 
twenty-ninth  to  the  thirtieth  week.  It  is  of  rather  peculiar  shape.  The  weight  of  this 
fffitus  was  1920  grammes  (about  4  pounds).  Its  gastric  capacity  was  18  c.  c.  (about  4-| 
drachms). 

The  next  stomach  (Fig.  59)  was  taken  at  about  the  thirty-second  week  from  a 
fostus  which  died  in  forty-five  minutes  from  the  time  of  its  birth.  The  gastric  capacity 
was  22  c.  c.  (5J  drachms).  The  weight  of  this  infant  was  1230  grammes  (2  pounds 
9  ounces). 

Fig  60. 


Foetal  stomach  (natural  size) ,  8  months  old.    Weight  of  foetus,  li40  grammes.    Gastric  capacity,  8  c.c. 


PREMATURE  INFANTS.  251 

The  next  stomach.  (Fig.  60)  was  taken  from  a  foetus  born  at  about  the  thirty-second 
week  of  intra-uterine  hfe,  and  weighmg  1440  grammes  (about  3  pounds).  Its  gastric 
capacity  was  8  c.c.  (about  2  drachms). 

Sweat-Glands. — The  function  of  the  sweat-glands  is,  as  a  rule,  not 
developed  at  birth,  and  we  do  not  expect  the  premat-ure  infant  in  the  early- 
weeks  of  life  to  perspire.  There  is,  however,  a  great  variation  as  to  the 
time  of  the  development  of  the  function  of  the  sweat-glands.  In  an  infant 
premature  at  seven  and  one-half  months  we  have  noticed  free  perspiration 
take  place  after  it  had  been  born  one  week. 

Feet. — Some  dissections  made  by  Dane  on  the  feet  of  an  infant  pre- 
mature at  the  seventh  month  show  that  the  foot  at  this  stage  of  develop- 
ment closely  approaches  in  external  appearances  the  well-developed  foot 
of  the  adult.  The  dissections  also  show  a  remarkably  well-constructed 
bony  framework. 

Gastric  Capacity. — As  the  question  of  the  proper  amount  of  food  to 
be  given  to  a  premature  infant  is  of  the  utmost  importance,  it  is  well  to 
know  about  what  the  average  gastric  capacity  of  the  foetus  is  during  the 
later  months  of  intra-uterine  life.  No  series  of  complete  and  reliable  ob- 
servations on  this  point  have  been  made,  that  we  know  of,  and  the  rules 
by  which  we  are  guided  must  for  the  present  be  very  general  ones.  The 
less  the  weight  of  the  infant,  the  less,  in  many  cases,  is  the  gastric  capacity. 

Intestinal  Contents. — The  meconium  in  premature  infants  presents 
the  same  appearance  as  is  seen  in  infants  at  term.  When  the  food  is 
properly  regulated,  the  faecal  discharges  assume  the  consistency  and  color 
w^hich  are  seen  in  those  of  infants  who  have  been  born  at  term.  This 
color  in  its  usual  varieties  is  well  represented  in  Plate  III.,  6,  7,  8,  9, 
facing  page  77. 

Amylolytic  Function. — The  amylolytic  function  of  the  infant  at  term 
is  so  slightly  developed  that  we  may  safely  assume  that  it  should  not  be 
depended  upon  for  the  digestion  of  starch  in  the  premature  infant  under 
any  circumstances. 

Sugar. — ^Although  we  must  assume  that  the  function  of  absorbing 
sugar  is  not  developed  to  the  same  extent  in  the  premature  infant  as  in 
the  infant  at  term,  yet,  in  all  probability,  it  is  more  highly  developed  than 
the  other  functions  of  digestion.  Sugar  is  needed  to  keep  up  the  animal 
heat  of  the  premature  infant,  which  is  so  very  much  more  readily  lessened 
than  in  the  infant  at  term.  Sugar,  therefore,  is  an  important  element  in 
the  premature  infant's  food,  but  should  be  given  at  first  in  a  much 
lower  percentage  than  later,  when  the  equihbrium  of  the  gastro-enteric 
tract  has  been  acquired. 

Fat  and  Proteid  Digestion. — The  function  of  digesting  fats  and  proteids 
is  in  a  much  more  undeveloped  condition  in  the  premature  infant  than  in 
the  infant  born  at  term,  and  should,  therefore,  not  be  depended  upon  to 
the  same  degree  as  can  safely  be  done  in  arranging  the  food  for  the  older 
infant.     Much  smaller  percentages  of  these  elements  should  be  given  to 


■2r,-2  '         I'KDiA'rr.Ks. 

the  premature  infant  than  to  the  infant  at  term,  both  for  purposes  of  di- 
gestion and  of  absorption,  for,  in  all  probability,  the  power  of  absorption 
of  the  gastro-enteric  tract  in  premature  infants  is  in  a  very  undeveloped 
condition.  As  small  a  percentage  of  caseinogen  in  the  total  proteid  as 
possible  should  be  given,  the,  ^vhey-proteids  being  increased  to  the  maxi- 
mum perc-entage  (<).90)  as  rapidly  as  digestion  permits. 

KmxEY. — We  should  expect,  from  the  lack  of  development  of  tlie 
kidney  in  premature  infants,  to  find  a  considerable  deposit  of  uric  acid, 
such  as  has  already  been  descrilDed  as  appearing  in  the  early  days  of  life 
in  infants  at  term.  (Plate  III..  1,  facing  page  77.)  This  is.  in  fact,  the 
case,  and  the  appearance  of  uric  acid  on  the  napkins  of  premature  infants 
is.  therefore,  not  necessarily  to  be  looked  upon  as  denoting  an  abnormal 
condition.  It  should,  however,  be  carefully  watched,  for  when  it  becomes 
excessive  it  is  an  indication  that  the  infant's  food  has  not  been  properly 
adjusted  to  its  digestive  powers  and  that  the  infant  may  soon  begin  to  fail. 

CmcuLATiox. — The  heart  in  premature  infants  has  not  yet  arrived  at 
the  complete  stage  of  development  needed  to  render  it  a  reliable  central 
force  which  can  fulfil  the  demands  that  will  be  made  on  it  in  the  external 
Avorld  to  sustain  the  equililDrium  of  the  circulation.  Therefore  as  little 
work  as  is  possible  should  be  thrown  upon  the  heart,  and  the  infant 
should  be  kept  quiet,  and  not  be  carried  about,  as  is  customary  with 
infants  born  at  term.  In  a  number  of  cases  which  we  have  carefully  ex- 
amined we  have  failed  to  detect  a  cardiac  mui'mur.  wiiiili  leads  us  to  tliink 
that  the  foramen  ovale  closes  soon  after  birth  in  the  same  manner  as  it 
does  in  the  infant  at  term. 

AxDiAL  Heat. — The  animal  heat  of  the  premature  infant  is  much  more 
easily  reduced,  and  is  even  more  important  to  its  vitality,  than  it  is  in 
the  infant  at  term.  Following  the  rule  that  the  smaller  the  size  of  the 
human  being  the  greater  proportionately  is  the  entire  surface,  and,  there- 
fore, the  greater  the  opportunity  for  lowering  its  temperature,  an  atmos- 
-phere  which  is  suitable  for  the  infant  at  term  is  too  cold  for  the  premature 
infant. 

Premature  infants  should  be  thoroughly  protected  from  changes  of 
temperature  of  the  atmosphere  in  which  they  live,  and  this  temperature 
should  be  raised  to  a  point  which  ^Yi\\  correspond  in  some  degree  to  that 
of  intra-uterine  life. 

Air. — Just  as  a  necessity  exists  for  the  premature  infant  to  live  for 
some  weeks  in  an  atmosphere  in  which  the  air  approaches  in  its  tempera- 
ture the  warmth  which  exists  in  intra-uterine  life,  so  is  it  almost  to  the 
same  desrree  important  that  the  ah'  Avhich  it  breathes  should  be  free  from 
dust  and  micro-organisms.  The  lung  is  in  a  very  undeveloped  condition, 
and  although  it  may  be  sufficiently  developed  to  cam'  on  the  function 
required  of  it  in  extra-uterine  life,  yet  all  its  tissues  are  exceedingly  sensi- 
tive, as  are  those  of  the  nose  and  the  naso-pharynx  through  which  the 
au'  must  be  introduced  to  the  lungs.     The  air  of  the  ordinary  room  in 


PREMATURE    L\FA.\TS. 


'1^6 


which  infants  live  when  they  are  born  necessarily  contains  many  impuri- 
ties, both' irritating  and  morbid.  This  irritation  of  the  respiratory  passages 
may  of  itself  be  sufficient  to  reduce  the  vitality  of  the  infant  beyond  the 
Umits  of  life.  In  addition  to  this,  as  the  mucous  membranes  of  the  pjre- 
mature  infant  are  not  fully  developed,  the  infant  is  more  vulnerable  to  the 
invasion  of  pathogenic  organisms  than  at  a  later  period. 

Touch. — Premature  infants  have  to  be  carefully  handled,  as  they  die 
easily  from  influences  which  would  have  little  or  no  effect  upon  the 
infant  born  at  term.  In  intra-uterine  life  they  are  floating  in  a  tluid  which 
practically  prevents  what  in  the  external  world  corresponds  to  handling. 
While  they  are  living  in  the  amniotic  fluid  they  are  almost  completely 
protected  fi'om  the  influence  of  touch,  wliich  necessarily  affects  them  as 
soon  as  they  are  born.  Touch,  then,  is  an  important  element,  to  be 
avoided  as  much  as  possible  when  the  premature  infant  is  born,  as  it  has 
a  decided  tendency  to  lower  the  vitality. 

An  instance  of  the  care  which  is  needed  to  preserve  the  lives  of  these 
infants  came  to  my  notice  in  the  case  of  an  infant  premature  at  eight 
months  which  was  in  my  service  at  the  City  Hospital. 

During  the  first  week  or  ten  daj's  of  its  life  this  infant  was  in  charge  of  an  un- 
usually careful  and  experienced  nurse,  who  appreciated  the  risk  of  handling  it.  It  was 
gaining  in  weight  and  was  doing  well  ;  but  unfortunately  another  nurse  was  substi- 
tuted who  did  not  understand  this  class  of  infants  so  well.  She  allowed  the  patients 
in  the  ward  to  handle  the  infant,  to  talk  to  it,  and  to  suri'ound  it  with  various  similar 
deleterious  influences.  For  a  few  days  it  lost  in  weight,  and  then  it  suddenly  died. 
There  is  no  doubt  that  it  was  unable  to  withstand  the  amount  of  handling,  which  would 
have  done  no  harm  to  an  older  infant. 

Light. — The  premature  infant  should  live  in  comparative  darkness 
during  the  early  weeks  of  its  life.  Light  is  not  rec|uisite  for  the  develop- 
ment of  the  infant  in  the  earlier  stages  of  its  existence,  and  too  much  light 
will  impair  its  vitality.  It  is  important  to  adapt  the  light  to  the  stage  of 
its  development,  and  gradually  to  accustom  it  to  more  light  as  it  grows 
older. 

Sound. — In  the  normal  intra-uterine  conditions  the  intant  is  very 
slightly  exposed  to  sound,  and  all  its  functions  are  adapted  to  silence 
rather  than  to  the  many  noises  which  unavoidably  surround  it  m  the  ex- 
ternal world.  We  should  therefore  so  arrange  that  from  the  minute  it  is 
bom  it  is  protected  from  noise. 

Pulse,  Temperature,  and  Piespiration. — We  have  not  very  exact  records 
of  the  average  pulse  temperature,  and  respiration  found  in  premature 
infants.  These  infants  seem  to  present  rather  irregular  types  of  temper- 
ature and  pulse,  as  well  as  of  respiration.  They  have  to  be  so  carefully 
handled  that  observations  as  to  these  physical  signs  must  be  made  with 
great  caution.  The  main  point  in  regard  to  these  three  conditions  of  the 
premature  infjuit  is  that  they  are  all  represented  by  irregularity.     The  tem- 


254  PEDIATRICS. 

perature  of  the  premature  infant,  when  it  has  once  begun  to  gain  in  weight 
and  to  thrive,  is  usually  a  little  above  the  normal  temperature  of  the  infant 
at  term.  Before  it  has  begun  to  gain  in  weight  and  wlien  its  vitality  is 
much  depressed,  the  temperature,  as  would  naturally  be  expected,  is  rather 
below  the  normal  standard  ;  and  we  should  watch  this  sign  with  the  great- 
est solicitude,  as  a  decided  and  continuous  depression  is  often  indicative 
of  approaching  death.  The  p?(/.s^  is  difficult  to  take  in  the  premature 
infant,  and,  as  a  rule,  is  somewhat  quicker  than  in  the  infant  at  term. 
The  respirations,  irregular  in  the  infant  at  term,  are  still  more  irregular  in 
the  premature  infant,  at  times  being  rapid  for  a  few  seconds,  and  then 
becoming  almost  imperceptible  for  some  minutes. 

APPEARANCE  AT  BIRTH. — The  picture  of  a  premature  infant  in 
the  early  days  of  life  is  cpite  characteristic.  Besides  its  very  small  size, 
as  shown  in  Fig.  61,  where  the  size  is  compared  with  the  nurse's  hand, 

Pig.  61. 


Infant  premature  at  slvciuIi  month.    Birth-^vei'-:ht.  1740  grammes.    A-':.  1-  ilay^ ;  v.L-ight,  1540  gramme; 


it  shows  in  varying  degrees  an  absence  of  the  life  and  vigor  which  is 
seen  in  the  fully  developed  infant  at  term.  It  is  emaciated,  its  skin  being 
soft,  ^^Tinkled.  and  sho^^*ing  very  little  subcutaneous  fat.  Its  head  is 
large,  its  abdomen  broad  and  distended,  and  its  limbs  puny.  According 
jto  the  stage  of  its  development  it  may  or  may  not  have  the  remains  of  the 
hair  (lanugo)  on  its  body  which  was  present  in  uterine  life,  and  in  like 
manner  its  nails  may  or  may  not  be  well  formed.  Its  face  has  a  senile 
expression  and  it  is  torpid  and  extremely  somnolent.  The  eyes  are 
closed.  Its  cry  is  ver^'^  feeble.  The  surface  temperature  is  usually  cool, 
the  extremities  seldom  move.  The  respirations  are  ven,'  superficial  and 
irregular,  often  ceasing  altogether  for  a  few  seconds.  The  power  to  suck 
and  even  to  swallow  is  often  slight.  These  signs  evidently  indicate  that 
the  ^itality  is  very  low.  and  if  the  weight  is  below  three  or  four  pounds 
and  the  length  less  than  eighteen  or  nineteen  inches,  that  the  functions 
and  organs  are  not  developed  sufficiently  for  use.  and  that  unless  unusual 
care  is  taken  in  the  treatment  of  such  cases,  they  will  soon  die. 

Treatment. — The  treatment  of  a  premature  infant  should  be  begun  at 
once,  as  every  minute  of  the  exposure  to  which  infants  at  term  are  usually 
with  safety  submitted  is  of  the  greatest  danger  to  the  premature  infant,  and 


PREMATURE   INFANTS.  255 

greatly  enhances  the  difficulty  of  saving  its  life.  The  bodily  temperature, 
on  which  the  vitality  is  dependent,  is  reduced  very  rapidly,  and  exposure 
to  such  conditions  as  are  abnormal  to  those  of  intra-uterine  life  and  to 
undeveloped  organs  is  to  be  at  once  guarded  against.  The  abnormal 
conditions  to  be  avoided  are  light,  sound,  touch,  cold  and  impure  air.  To 
accomplish  this  the  following  rules  are  indicated : 

I.  There  should  be  a  receptacle  w^hich  shall  guard  the  infant  from  the 
deleterious  influences  of  extra-uterine  life. 

II.  The  receptacle  should  be  such  that  it  can  be  obtained  quickly  and 
transported  rapidly,  and  therefore  should  be  kept  at  some  central  and  con- 
venient station. 

III.  The  place  where  the  receptacle  is  kept  should  be  free  from  the  in- 
fluence of  any  disease. 

IV.  The  receptacle  should  be  so  constructed  as  to  make  it  possible  for 
it  to  be  absolutely  cleansed  and  disinfected  each  time  after  it  has  been  used, 
hence  it  should  be  made  of  metal. 

V.  The  receptacle  should,  as  soon  as  the  infant  is  placed  in  it,  be 
under  the  observation  of  trained  nurses  night  and  day. 

VI.  The  food  for  the  infant  should  be  regulated  with  the  greatest  pre- 
cision, with  the  closest  attention  to  minute  details,  and  if  possible,  at  a 
milk-laboratory. 

VII.  The  premature  infant  should  not  be  bathed,  but  should  be  rapidly 
covered  with  warm,  fresh  sweet  oil,  and  wrapped  up  in  absorbent  cot- 
ton, only  the  face  being  left  exposed.  The  cotton  around  the  buttocks 
should  be  separate  from  that  around  the  body,  head,  and  upper  extremi- 
ties, so  that  it  can  be  changed  oftener,  as  after  the  discharge  of  urine  and 
faeces.  The  remaining  cotton  need  not  be  changed  oftener  than  once  in 
forty-eight  hours,  and  at  each  change  of  cotton  the  oil  can  be  reapplied. 

It  will  be  found  that  the  cotton  is  remarkably  cleansing,  and  will  ob- 
viate entirely  the  necessity  for  using  water.  The  cotton  and  oil  should  be 
thoroughly  warmed  before  being  used.  The  infant  should  not  be  re- 
moved from  its  receptacle  when  these  changes  are  being  made  or  when  it 
is  fed.  The  surroundings  and  receptacle  should  be  adapted  to  the  indica- 
tions just  stated.  All  the  possible  causes  which  may  reduce  the  vitality 
must  be  thoroughly  understood  and  obviated,  and  it  must  be  appreciated 
that  a  failure  to  recognize  and  obviate  any  one  of  these  causes  may  defeat 
the  benefit  which  should  arise  from  attending  to  all  the  others.  The 
premature  infant,  therefore,  should,  so  far  as  possible,  be  restored  to  the 
condition  that  it  has  been  forced  out  of, — namely,  a  condition  of  darkness, 
silence,  warmth,  and  a  medium  free  from  physical  shock  and  pathogenic 
micro-organisms. 

Weig-ht. — It  is  important  to  remember  that  the  weight  of  premature 
infants  of  the  same  age  varies  at  birth,  just  as  we  have  seen  in  the  case 
of  infants  born  at  term. 

In  treating  these  cases,  observance  of  their  weight  is  of  the  greatest 


256  PEDIATRICS. 

importance,  and  until  we  have  obtained  a  regular  progressive  daily  in- 
crease in  their  weight  we  are  never  sure  that  they  are  thriving  sufficiently 
to  live.  The  daily  gain  which  the  premature  infant  should  make  has  not 
yet  been  determined,  but  it  is  much  less  than  is  expected  when  an  infant 
is  born  at  full  term,  and  may  be  stated  to  be  about  10  to  20  grammes  (^ 
to  I  ounce).  Any  decided  loss  in  weight,  such  as  30  to  40  grammes  (1 
to  IJ  ounces),  beyond  what  would  occur  from  natural  causes,  should 
make  us  look  upon  the  infant  as  being  in  a  critical  condition  and  impress 
upon  us  the  importance  of  taking  active  measures  to  prevent  further  loss. 
This  loss  in  weight  must,  as  it  is  relatively  so  small,  be  carefully  adjusted 
to  the  loss  which  naturally  occurs  from  the  faecal  discharges.  Thus,  tlie 
total  amount  of  loss  in  weight  from  the  faecal  discharges  may  amount  in 
these  premature  infants  to  from  30  to  60  grammes  (1  to  2  ounces)  for  each 
faecal  discharge,  and  this  may  entail  a  considerable  loss  of  the  infant's 
weight  in  the  twenty-four  hours  beyond  that  occasioned  by  defective 
nutrition. 

The  knowledge  of  the  daily  weight  of  a  premature  infant  is  the  prin- 
cipal index  of  the  changes  in  its  vitality  which  occur  very  rapidly,  and  it 
is  by  the  Aveight  that  we  are  guided  in  our  daily  adaptation  of  the  food  to 
the  infant's  condition,  and  are  also  informed  as  to  whether  greater  or  less 
warmth,  more  oxygen,  or  stimulants  are  indicated. 

The  handling,  however,  which  is  usually  necessary  to  obtain  the 
weight  is  dangerous,  as  it  reduces  the  vitality.  This  danger  should  be 
obviated  by  having  the  receptacle  balanced  on  correct  and  sensitive 
scales.  The  premature  infant's  life  is  so  difficult  to  preserve  that  we 
should  make  use  of  every  device  which  our  ingenuity  can  suggest  and 
which  is  within  the  limits  of  possibility  of  the  especial  case  which  we  are 
called  upon  to  treat.  The  receptacle  for  the  immediate  occupation  of  the 
newly  born  premature  infant  therefore  becomes  a  very  important  part 
of  the  treatment. 

Receptacle. — In  the  treatment  of  premature  infants  only  one  of  the 
principal  methods  of  maintaining  their  viability  usually  receives  much  at- 
tention. It  is  commonly  supposed  that  if  the  atmosphere  which  sur- 
rounds the  infant  is  kept  at  a  sufficiently  high  temperature  all  that  is 
requisite  has  been  done  for  its  safety.  This  is  sometimes  accomplished 
by  placing  the  infant  in  a  room  w^here  the  temperature  is  as  high  as  the 
nurse  in  charge  of  it  is  able  to  endure.  This  procedure  is  necessarily  a 
very  uncomfortable  one  for  the  nurse,  and  at  times  renders  it  almost  im- 
possible for  her  to  use  her  mind  intelligently.  It  also  requires  a  much 
more  frequent  change  of  nurses  than  would  be  the  case  if  the  atmosphere 
of  the  room  were  cooler.  Another  means  of  preventing  undue  loss  of 
heat  is  to  wrap  the  infant  in  cotton-wool  and  place  it  in  a  basket  lined 
with  felt  or  quilted  cotton,  the  heat  being  supplied  with  hot-water  bottles 
or  heated  by  the  electric  heating  pads  sold  under  the  name  of  eloctro- 
Iherms. 


PREMATURE   INFANTS. 


257 


Fig.  62. 


Incubator. — Incubators  have  been  used  for  many  years  in  different 
parts  of  the  world,  notably  in  Paris.  They  are  of  different  forms,  some 
better  adapted  than  others  for  carrying  out  the  different  factors  of  the 
problem. 

The  name  incubator  is  a  misnomer,  for  incubation  means  hatching, 
and  in  the  precise  sense  of  the  word,  the  premature  infant  is  already 
hatched  and  has  been  in- 
cubated. What  we  ac- 
complish by  this  appara- 
tus is  analogous  ,to  what 
is  done  to  keep  up  the  ani- 
mal heat  and  preserve  the 
lives  of  young  chickens 
after  they  are  hatched,  and 
the  name  brooder  would 
be  more  applicable  to  ma- 
chines devised  for  pre- 
serving the  lives  of  prema- 
ture infants  than  the  term 
incubator.  The  word  in- 
cubator is,  however,  so 
generally  used  to  repre- 
sent an  apparatus  in- 
tended to  preserve  the 
premature  infant's  life  un- 
til it  has  attained  the  age 
of  two  hundred  and  eighty 
days,  that  it  will,  in  all 
probability,  for  the  pres- 
ent be  retained. 

Several  varieties  of  in- 
cubators are  no^v  manu- 
factured. The  accom- 
panying cut  (Fig.  62j 
shows  the  general  prin- 
ciples embodied  in  the 
construction  of  some  of 
them.  It  is  made  by  the 
Hospital  Supply  Company 
of  New  York : 


.1,  air  funnel ;  B,  heating  coils  ;  C,  air-heating  chamber;  D, 
battery  of  4  cells  ;  F,  gas  Bunsen  burner  ;  G,  weight  to  balance 
cover  ;  H,  cover  at  air  chamber :  A',  thermometer  ;  L,  hygrometer  ; 
i[,  swinging  wire  mattress ;  N,  regulator  ;  0,  air  inlet  connected 
with  funnel  ^-1 ;  R,  plate  to  disperse  the  air  ;  .S',  sliding  window  ; 
U,  magnets  ;  E,  tray  for  water  ;   V,  wheel  to  indicate  current. 


Directions.— Having  put  up  the  incubator  as  shown  by  the  illustration,  adjust  the  weight  (G)  so  as 
to  allow  the  cover  (H)  to  hang  lightly  on  the  top  of  chamber  (C)-,  make  a  short  circuit  by  placing  a  piece 
of  metal  (knife  blade,  key,  etc.)  over  the  binding  posts  of  the  thermometer  (H),  to  see  if  the  regulator 
works  properly,  by  raising  the  cover  (H).  If  this  should  not  be  the  case,  move  the  weight  accordingly 
forward  or  backward.  Put  absorbent  cotton  in  the  funnel  (A).  The  box  is  to  be  filled  half  with  clear 
water  to  impart  moisture  to  the  air.  Light  the  gas  burner  (F)  to  heat  the  air  in  the  chamber  (C).  The 
heated  air  passes  through  the  tubes  (B)  and  heats  the  air  in  the  incubator,  which  disperses  under  the 

17 


258 


PEDIATRICS. 


plate  f  A')  and  rises  to  pass  thi-oiish  tho  chimney.  Wlien  the  air  is  sufficiently  heated,  lliere  will  be  a 
regular  current  of  the  air  which  is  indicated  by  the  rot^ition  of  the  wheel  in  the  top  glass  part  of  the 
chimney.  When  the  thermometer  registers  about  88°  F.,  put  the  baby  in  the  incubator.  At  90°  tempera- 
ture the  mercury  comes  in  contact  with  a  platinum  wire,  which  is  connected  with  the  regulator.  This 
causes  the  cover  (IT)  to  be  raised.  Tlie  hot  air  escapes  from  the  chamber  (C),  lowering  the  temperature 
in  the  incubator.  When  the  cover  comes  down  again,  causing  the  hot  air  to  pass  as  before,  through  the 
tubes  (B),  which  increases  auew  the  temperature  up  to  90°  The  temperature  can  also  be  regulated  by 
moving  the  burner  up  or  down  the  rod  (T). 

When  it  is  impossible  to  obtain  an  incubator  at  once  for  preserving 
the  premature  infant's  animal  heat,  it  can  be  treated  in  the  way  already 
referred  to,  by  placing  it  in  a  room  in  which  the  temperature  has  been 
raised  as  high  as  can  be  comfortably  borne  by  the  nurses,  and  in  a  basket 
heated  by  hot-water  bottles.     Such  a  case  is  represented  in  Fig.  63. 


Fk;.  iV^. 


Infant  premature  at  twenty-eighth  week.  Birth-weight,  1200  grammes.  Age,  14  weeks.  Treatea 
in  basket  heated  by  hot-water  bottles.  Temperature  of  air  in  basket  shown  by  thermometer  introduced 
between  the  side  of  the  basket  and  the  blanket. 


No  incubator  has  yet  been  devised  Avhich  can  be  called  ideal.  The 
problem  of  supplying  a  receptacle  in  which  a  constant  temperature  can  be 
maintained  is  met  by  such  a  contrivance  as  that  just  described.  The 
objection,  however,  to  this  and  to  similar  incubators  is  that  the  infant  is 
-obliged  to  breathe  air  which  is  of  the  same  temperature  as  that  in  which 
it  lies.  It  is  very  doubtful  if  such  a  condition  is  desirable.  We  believe 
that  the  ideal  requirements  call  for  some  means -of  maintaining  about  the 
infant  an  atmosphere  which  can  be  regulated  to  any  temperature  the 
physician  considers  necessary,  but  that  the  air  which  the  child  Jireathes 
should  be  pure,  fresh  and  considerably  lower  in  temperature  than  that  of 
the  incubator.  Our  recent  experiences  lead  us  to  favor  in  private  practice 
a  padded  crib  or  basket  such  as  has  been  described,  although  many 
objections  can  be  raised  against  this  method  of  treatment. 

Temperature  of  the  Incubator. — The  temperature  at  which  the  baby 
thrives  best  varies  in  different  cases,  according  to  its  age  and  vitality,  and 
there  is  great  difference  of  opinion  among  authorities  as  to  the  proper 
range — the  fundamental  principle  of  the  incubator  is  to  maintain  a  normal 
body  temperature.     We  should  therefore  not  allow  the  infant's  rectal 


PREMATURE    INFANTS.  259 

temperature  to  show  a  greater  variation  than  from  36.1°  to  37.2°  C.  (97°- 
99°  F.).  Subnormal  temperatures  must  be  treated  by  raising  tlie  tempera- 
ture of  the  incubator,  or  by  warm  baths,  as  recommended  by  Budin.  An 
elevated  rectal  temperatui"e  is  an  indication  to  lower  the  temperature  of 
the  incubator.  There  is  great  danger  in  maintaining  too  high  an  incubator 
temperature.  Hyperpyrexia,  gastric  or  intestinal  indigestion,  cyanosis, 
restlessness,  perspiration,  sudamina  and  rapid  loss  in  weight  may  all  be 
due  to  excess  of  heat. 

If  we  were  to  formulate  a  general  rule,  we  would  let  the  initial 
temperature  of  the  incubator  be  determined  by  the  weight  of  the  infant. 
When  it  weighs  1000  grammes  or  less,  the  temperature  should  be  35°  C. 
(95°  F.) ;  when  1500  grammes,  it  should  be  32.2°  C.  (90°  F.) ;  when  2000 
grammes,  it  should  be  29.-4°  C.  (85°  F.).  The  subsequent  temperature 
must  be  determined  by  close  observation  of  the  symptoms  and  varies  with 
the  condition  of  the  infant.  The  smaller  the  child,  as  a  rule,  the  slower 
one  should  be  in  reducing  the  temperature  and  the  longer  one  should  con- 
tinue the  use  of  the  incubator.  Four  to  eight  weeks  represents  the  usual 
period  of  incubation.  One  cannot  be  guided  wholly  by  the  age  of  the 
child. 

Nurses. — The  incubator  is  not  intended  to  obviate  the  necessity  of 
skilled  nursing.  On  the  contrary,  a  nurse  should  be  in  constant  attend- 
ance night  and  day.  She  should  have  all  the  details  of  the  infant's  care 
and  the  mechanism  of  the  incubator  explained  to  her  minutely,  for  an 
emergency  may  arise  at  any  time,  and  always  requires  to  be  dealt  with 
immediately. 

The  incubator  supplies  the  means  for  exact  treatment,  but  intelligent 
minds  and  trained  gentle  hands  are  indispensable.  The  nurse  should  fre- 
quently observe  the  infant  through  the  glass  lid,  and  should  be  certain 
that  the  anemometer  is  in  constant  motion. 

The  necessity  of  constant  watching  and  hourly  feedings  is  such  that  for 
the  first  few  weeks  two  nurses  are  essential  for  the  proper  care  of  the 
baby.  It  is,  moreover ,  of  the  greatest  importance  that  they  should  have 
had  previous  experience  with  premature  infants.  The  management  of 
these  cases  presents  difficulties  not  ordinarily  met  with  in  the  care  of  in- 
fants born  at  term,  and  it  requires  a  nurse  who  has  a  knowledge  of  the 
possible  emergencies  and  who  is  capable  of  dealing  with  them  promptly 
and  intelligently  on  her  own  initiative. 

Apparatus  Coxxected  with  the  Ixcubator. — A  stethoscope  with  rubber 
arms  and  small  cup  is  the  best  adapted  for  examining  the  infant  in  the 
incubator,  as  it  can  be  bent  in  any  direction,  and  is  suited  to  the  infant's 
size. 

A  piece  of  dark  cloth  should  be  kept  over  the  glass  lid,  or  the  top  of 
the  padded  crib,  to  exclude  the  light,  while  the  sun  should  be  allowed  to 
shine  freely  into  the  room.  The  air  in  the  room  should  be  frequently 
changed  and  kept  as  pure  as  possible.     The  room  should  be  absolutely 


260 


PEDIATRICS. 


Fig.  64. 


1 


-8 


free  from  dust  and  should  only  contain  some  polished  wood  chairs  and 
tables.  The  floor  should  be  bare,  and,  if  possible,  of  polished  hard  wood. 
The  method  of  feeding  the  infant  in  the  incubator  is  important.  It  fre- 
quently happens  that  the  premature  infant  is  too  weak  not  only  to  suck  the 
breast,  but  also  to  be  fed  from  the  bottle.  In  such 
cases  it  is  customary  to  use  a  spoon  or  a  medicine- 
dropper.  These,  however,  are  not  always  satisfactory 
instruments.  The  food  is  liable  to  be  spilled,  the  spoon 
or  dropper  has  to  be  frequently  filled,  and  much  time 
is  taken  to  complete  the  feeding.  The  door  of  the  incu- 
bator, also,  should  not  be  kept  open  for  a  longer  time 
than  is  necessary.  We  have  made  use  of  a  device 
suggested  by  Dr.  Breck.  It  is  simply  a  glass  cylin- 
der Fig.  64),  12  cm.  (4|  inches)  long  and  2.4  cm,  (1 
inch)  in  diameter.  The  cylinder  is  graduated  to  2  c.c 
(I  drachm),  and  holds  36  c.c.  (9  drachms).  It  is  shaped 
at  one  end  so  as  to  have  a  small  rubber  nipple  fitted  to 
it.  The  large  end  is  covered  by  a  rubber  cot.  The 
rubber  cot.  which  has  no  holes,  acts  as  an  air-reservoir, 
and  by  simply  introducing  the  small  perforated  nipple 
into  the  mouth  and  gently  pressing  the  rubber  cot  the 
food  is  slowly  forced  down  the  intant's  throat,  without 
choking  it  and  without  obliging  it  to  suck  or  apparently 
to  use  any  effort.  To  fill  the  tube  the  rubber  nipple 
and  cot  are  removed,  and  the  required  amount  of  food 
1  is  poured  in  at  the  lai^e  end,  while  the  small  end  of  the 
I  cylinder  is  plugg-ed  A^ith  a  rubber  stopper  shown  in  the 
figure  beside  the  feeder. 

This  method  of  feeding  is  especially  desirable  for  a 
Feeder  for  premature    ^^'^ak  prematurc  iufaut  in  au  incubator,  because  it  entails 
infants  (reduced  one-    210  loss  of  strensftli  ou  the  part  of  the  infant,  and  can  be 

half).  ^  .       ^  '  . 

easily  managed  by  the  right  hand  of  the  nurse,  while  her 
left  hand  supports  the  infant's  head.  This  method  is  far  preferable  to  that 
of  gavage,  which  is  not  so  easily  managed  by  the  nurse  and  is  more 
exhausting  to  the  infant. 

Food. — The  feeding  of  premature  infants  should  be  as  exact  as  pos-' 
sible.  If  the  infant  is  vigorous  enough  to  suck,  and  if  the  breast-milk  is  of 
proper  quality,  that  is,  not  too  strong,  the  infant  can  be  put  to  the  breast 
every  one  and  one-half  hours.  We  must  consider,  however,  certain 
disadvantages  of  nursing  premature  infants  which  do  not  arise  in  the 
nursing  of  infants  at  term.  Frequent  nursing,  such  as  every  hour,  which 
is  so  often  required  with  premature  infants,  tends  to  disturb  the  quality  of 
the  breast-milk  and  to  increase  the  solids.  This  is  often  disastrous  to  the 
infant,  as  the  least  overtaxing  of  its  digestion  may  prove  fatal.     Then, 


PREMATURE  INFANTS.  261 

again,  the  premature  infant  can  often  digest  only  much  louver  percentages 
of  fat,  sugar,  and  proteids  than  are  found  in  normal  breast-milk,  so  that  a 
normal  milk  may  prove  fatal  by  being  too  strong.  It  is  therefore  usually 
advisable  at  the  beginning  to  withdraw  the  breast-milk  by  means  of  a 
pump  or  by  milking  with  the  fingers,  dilute  it  with  one  or  two  parts  of 
water  and  give  it  with  a  Breck  feeder.  The  laboratory  method  of  feeding 
with  exact  and  low  percentages  gradually  increased  is  the  most  rational 
and  practical,  especially  if  the  infant  is  too  weak  to  nurse  at  the  breast,  or 
if  good  breast-milk  cannot  be  obtained. 

Caloric  Need  of  Premature  Infants. — The  caloric  need  of  a  premature 
infant  is  relatively  greater  than  that  of  a  full-term  infant,  partly  because  it 
digests  and  absorbs  a  smaller  proportion  of  the  caloric  value  of  the  food 
digested,  and  partly  because  it  loses  heat  faster,  owing  to  its  relatively 
larger  surface  area.  Morse  and  others  have  shown  that  the  gain  in  weight 
is  not  wholly  a  matter  of  calories,  as  of  two  infants  taking  the  same  number 
of  calories,  one  may  gain  two  or  even  three  times  as  much  as  the  other. 
Budin  states  that  most  premature  infants,  after  the  tenth  day,  recjuire  an 
energy  quotient  of  120-1-30  (when  breast-milk  was  the  food  used)  to  in- 
sure a  steady  gain  in  weight.  Zahorsky's  investigations  support  this  opinion. 
It  is  doubtful,  however,  if  any  definite  rule  can  be  laid  doAvn  as  to  the 
caloric  needs  of  premature  infants,  even  as  one  cannot  assert  that  any  one 
percentage  combination  of  milk  is  of  universal  application.  The  gain  in 
weight  is  dependent  upon  the  digestion  and  metabolism  of  each  individual 
baby,  and  we  know  that  these  conditions  are  influenced  as  much,  if  not 
more,  by  the  proportions  of  fats,  sugar  and  proteids  which  the  infant  can 
digest  as  by  the  caloric  value  of  the  food  as  a  whole.  This  is  as  true  of 
premature  infants  as  of  those  who  are  full  term. 

If  one  knows  the  percentage  composition  of  the  food  one  may  easily  estimate  its 
•caloric  value,  by  regarding  the  heat  value  of  the  fat  at  9.3  calories  to  each  gramme,  and 
the  proteids  and  sugar  as  4.1  calories  to  each  gramme.  If  the  twenty- four  hour 
amount  of  food  is  estimated  by  the  rules  given  below,  page  262,  the  number  of  calories 
ingested  is  obtained  by  multiplying  the  caloric  value  of  the  food  by  the  number  of  cubic 
centimetres  taken. 

The  enercjy  quotient  is  then  calculated  by  dividing  the  number  of  calories  in  the 
twenty-four  hour  amount  by  the  body  weight.  It  therefore  represents  the  number  of 
calories  per  kilogram  of  body  weight. 

Example :  A  premature  infant  weighs  1800  grammes,  on  the  tenth  day.  The  daily 
quantity  of  food  is  1800  -=-  5  ^  360  c.c.  The  caloric  value  of  breast-milk  is  650.  The 
energy  quotient  is  therefore  360  X  650  ^  1800  =  130. 

Amount. — The  amount  of  food  to  be  given  at  each  feeding  is  very 
important.  By  referring  to  the  weights  and  gastric  capacities  of  the  pre- 
mature infants  already  described  (Figs,  57,  58,  59,  page  251)  it  will  be 
seen  how  misleading  is  the  weight  of  the  infant  if  we  take  it  as  an  exact 
index  of  the  gastric  capacity.  We  must,  however,  take  the  weight  into 
account,  as,  from  even  the  imperfect  data  at  our  command,  the  weight  of 


262  PEDIATRICS. 

premature  infants  appears  to  ])car  a  decided  relation  to  their  gastric 
capacity.  We  sliould  at  least  be  more  inclined  to  increase  rapidly  the 
initial  amount  of  fooct  given  in  the  case  of  an  infant  of  large  weight  than 
in  that  of  a  small  one.  It  is  better  to  begin  Avith  too  small  rather  than  too 
large  a  quantity.  By  Avatching  carefully  for  signs  of  hunger,  a  desire 
which  the  infant  expresses  by  feeble  but  continuous  cries,  which  stop 
when  the  food  is  given  to  it,  we  can  gradually  increase  the  amount  until  it 
seems  to  Avant  it  at  regular  intervals,  is  satisfied,  and  sleeps  quietly  during 
the  intervals  of  feeding. 

By  referring  to  the  foetal  stomachs  represented  in  Figs.  57,  58,  59,  60, 
pages  251,  it  will  be  understood  that  it  is  safer  to  begin  with  4  or 
5  c.c.  (about  1  drachm)  and  gradually  to  increase  the  amount  up  to  a  point 
Avhere  our  very  imperfect  knowledge  on  this  subject,  derived  partly  from 
the  weight  of  the  infant,  makes  us  believe  that  the  stomach  is  full,  than  to 
begin  at  once  with  the  larger  amount.  It  is  absolutely  necessary  that  we 
should  avoid  undue  distention  of  the  stomach,  as  this  may  prove  fatal. 

Zahorsky  offers  the  following  practical  rules  for  those  who  do  not  wish 
to  calculate  the  daily  amount  of  food  on  the  basis  of  the  energy  quotient : 

I.  Before  the  tenth  day — Divide  the  weight  of  the  infantby  seventy  (70) 
and  multiply  the  quotient  by  the  age  plus  two  (2). 

II.  After  the  tenth  day — Divide  the  body  weight  by  five  (5).  This  rule 
Avas  previously  recommended  by  Budin.  The  amount  of  each  feeding  is 
then  calculated  by  dividing  this  twenty-four  hour  amount  by  the  number 
of  feedings. 

Intervals. — The  premature  infant's  stomach  is  small,  and  is,  in  all 
probability,  emptied  quickly,  and,  as  food  is  necessary  for  keeping  up  the 
animal  heat  recpired  for  the  maintenance  of  its  life,  the  intervals  of  feed- 
ing should  be  much  shorter  than  those  required  for  the  infant  at  term.  In 
the  early  days,  and  in  fact  Aveeks  of  life,  Ave  have  found  that  it  is  better  to 
feed  the  premature  infant  regularly  every  hour,  or  from  22  to  24  times  a 
_day.  In  3  or  4  Aveeks  after  birth,  if  it  is  gaining  in  Aveight  and  is  digesting 
Avell,  these  intervals  can  be  lengthened,  the  number  of  feedings  being 
reduced  to  14  or  16,  and  by  the  time  it  arrives  at  term  Ave  can  usually 
make  the  feeding  intervals  two  hours,  10  feedings  in  24  hours.  The 
smaller  the  infant,  the  more  frequent  Avill  the  feedings  be  as  a  rule. 

Percentag-es. — The  careful  adjustment  of  the  premature  infant's  food 
to  its  digestive  organs  is  of  even  greater  importance  than  in  the  case  of  an 
infant  at  term.  There  is  no  doubt  that  if  Ave  consider  the  hypersensitive 
condition  and  the  undeveloped  state  of  the  digestive  organs  prior  to  birth, 
the  most  exact  adjustment  of  the  food  to  these  digestive  organs  is  abso- 
lutely necessary  Avhen  a  Avet  nurse  cannot  be  obtained.  This  adjustment 
is  best  accomplished  by  means  of  carefully  prepared  prescriptions  at  the 
milk-laboratory.  Through  this  instrument  of  precision  three  important 
advantages  are  gained :  (1)  Ave  insure  a  clean  food  free  from  micro-organ- 
isms ;   (2)  Ave  can  obtain  low  and  properly  balanced  percentages  of  the 


PREMATURE  IXFAXTS.  263 

constituents  of  tlie  milk ;  (3)  we  have  at  any  time,  the  power  of  exactly 
varying,  to  within  a  fraction  of  one-half  of  one  per  cent.,  the  percentages 
of  the  three  most  important  elements  of  the  milk, — namely,  the  fat,  the 
sugar,  and  the  proteids.  In  addition  to  these  latter  two  advantages  pos- 
sessed by  the  substitute  over  the  maternal  method  of  feeding  are  others 
of  almost  equal  importance.  One  advantage  is  the  absence  of  variation 
in  the  substitute  food  arising  from  emotional  causes,  and  another  is  that 
the  infant  need  not  be  taken  from  the  incubator  to  be  fed. 

In  feeding  premature  infants  upon  a  modified  cow's  milk  we  find,  as  in 
the  case  of  infants  born  at  term,  that  we  cannot  give  a  milk  of  as  high  a 
percentage  composition  as  Avhen  breast-milk  is  used.  It  is  even  more 
necessary  in  premature  infants  to  begin  with  very  weak  modifications,  and 
to  increase  the  strength  of  the  food  very  gradually.  The  energy  cjuotients 
will  of  necessity  be  considerably  lower  in  the  early  days  of  life  than  those 
which  are  given  as  the  result  of  observations  on  breast-fed  infants.  We 
know  of  no  general  reliable  data  as  to  what  the  energy  quotient  should  be, 
as  in  our  experience  premature  infants,  as  well  as  infants  born  at  term, 
show  great  variation  in  their  capacity  to  digest  cow's  milk.  They  must  be 
fed  according  to  the  general  principles  of  percentage  feeding,  which  will  be 
described  later.  Zahorsky's  rules  for  determining  the  quantity  of  milk  in 
twenty-four  hours  (page  262)  will,  as  a  rule,  hold,  Avhether  the  feeding  is 
breast-milk  or  modified  cow's  milk. 

The  following  prescription  is  the  one  which  wc  should  begin  ^vitll  in 
feeding  an  infant  premature  at  the  twenty-eighth  week  : 

Prescription  9. 

R  Fat 1.00 

Sugar 4.00 

Whey-Proteids 0. 25 

Caseinogen    0.25 

Lime-water 2.50 

24  feedings. 

Amount  (see  page  262) . 
The  caloric  value  of  such  a  food  is  277.5.    By  increasing  the  Avhey-j)roteids  to  0.90, 
the  caloric  value  is  raised  to  304. 

If  the  infant  is  over  thirty-two  weeks,  or  if  it  is  unusually  large  for  its 
age,  and  especially  if  it  is  unsatisfied,  it  is  well  in  a  few  days  to  change  the 
prescription  to  the  following : 

Prescriptiox  10. 

R   Fat 1.50 

Sugar 5.00 

Whey-proteids 0. 25 

Caseinogen 0.25 

Lime-water 2.50 

24  feedings. 

Amount  (see  page  262 ) . 
The  caloric  value  of  such  a  food  is  305.     By  increasing  the  whey-proteids  to  0.90, 
the  caloric  value  is  raised  to  391.6. 


264  PEDIATRirs. 

If  the  infant  is  over  tliirty-six  weeks,  the  milk  should,  after  three  or 
four  days,  be  changed  to  : 

Prescription  11. 

R   Fat 2.00 

Sugar ().  00 

Whey-protfeids 0.90 

Caseinogen 0. 2.^ 

Lime-water 2.50 

2-i  feedings. 

Amount  (see  page  262.) 

The  caloric  value  of  such  a  food  is  479. 

The  infant,  however,  under  all  circumstances,  must  be  watched  criti- 
cally, and  any  or  all  of  the  percentages  of  the  elements  or  amounts  of  the 
food  increased  or  decreased  according  to  tlie  individual  indications. 

When  the  infant  is  born  at  tlie  thirty-eighth  or  thirty-ninth  week  its 
development  is  usually  so  near  that  of  the  infant  of  term  that  the  incubator 
will  not  be  needed,  and  the  food  can  be  given  in  about  the  proportions 
which  would  be  adapted  to  the  early  days  of  the  infant  at  term  (Formula  4, 
page  189). 

Prognosis. — The  prognosis  in  a  premature  infant  during  the  early 
weeks  of  its  life  and  until  it  is  steadily  gaining  in  weight  must  be  guarded, 
as  the  mortality  rate  is  very  high,  and  these  infants  are  apt  to  die  suddenly 
simply  from  a  lack  of  vitality.  The  younger  the  infant  and  the  less  its 
weight,  the  greater  is  the  danger  of  its  dying.  The  most  frequent  causes 
of  death  among  premature  infants  are  a  lack  of  development  of  the  thorax 
or  lungs,  atelectasis,  an  insufficient  supply  of  fresh  air,  improperly  cleansed 
incubators,  leading  to  various  forms  of  infection,  undue  exposure,  careless 
handling,  and  improper  feeding. 

The  following  tables  show  the  relative  mortahty  according  to  weight  at 
birth  of  two  series  of  babies  treated  in  incubators  : 

TABLE   52. 

Shotving  Death-Rate  of  Premature  Infants  at  the  Debiles  de  la  Maternite,  Paris,  1895- 

'96  and  '97.     (Budin.) 


Weight 

No.  of 

Deaths. 

Li 

ving. 

Category. 

Grammes. 

Infants. 

No. 

Pef  Cent. 

No. 

Per  Cent. 

1 

le.?s  than  1200 

40 

38 

95.0 

2 

5.0 

2 

1200-1499 

146 

124 

85.0 

22 

15.0 

3 

1500-1999 

432 

265 

6L3 

167 

38.6 

4 

2000  or  more 

212 

69 

32.5 

143 

67.5 

TABLE   53. 

living  Death-rate  of  Premature  Infants 

at  the  Clinique  Tarnier, 

,  Paris,  189S.    {Bu 

Weight 

No.  of 

Deaths. 

Living. 

Category. 

Grammes. 

Infants. 

No. 

Per  Cent. 

No. 

Per  Cent. 

1 

less  than  1200 

1 

1 

100.0 

0 

0.0 

2 

1200-1499 

5 

3 

60.0 

2 

40.0 

3 

1500-1999 

30 

4 

13.3 

26 

86.7 

4 

2000  or  more 

lOS 

7 

6.4 

101 

93.6 

PREMATURE    INFANTS. 


265 


The  following  record  and  chart  are  those  of  a  premature  infant  who 
was  kept  in  a  room  with  a  temperature  of  23.8°  C.  (75°  F.)  and  in  a 
basket  heated  to  29.4°  C.  (85  F.). 


Day  of  Life.  Grammes. 

Birth-weight 2964 

Third.... ^ 2724 

Sixth....' 2814 

Ninth 2964 

Thirteenth 3178 

Sixteenth 3388 

Twentieth 3598 

Twenty-third 3812 

Twentj^-seventh 4116 

Thirtieth 4236 

Thirty-third 4476 

Thirty-seventh 4600 

Forty-first 4840 

Forty-fourth 4900 

Forty-eighth 4994 

Fifty-first 5084 

Fifty-fifth 5234 

Fifty-eighth 5324 

Sixtv-first 5384 


TARLE  54. 

s  of  Infant  Premature  at  Thirty-two  Weeks. 

Pound 

s.   Oz.) 

Remarks. 

(   6 

8) 

Cow's  milk,  with  spoon. 

(    6 

0) 

Mother's  milk,  with  spoon. 

(    6 

3) 

Mother's  milk,  with  spoon. 

(    6 

8) 

Mother's  milk  direct  from  breast. 

(   T 

0) 

Mother's  milk  direct  from  breast. 

(   7 

^) 

Modified  milk. 

(    ' 

14) 

Modified  milk. 

{   8 

6) 

Modified  milk. 

(   9 

1) 

Modified  milk. 

(   9 

5) 

Modified  milk. 

(   9 

13) 

Modified  milk. 

(10 

2) 

Modified  milk. 

(10 

10) 

Modified  milk. 

(10 

12) 

Modified  milk. 

(11 

0) 

Modified  milk. 

(11 

3) 

Modified  milk. 

(11 

8) 

Modified  milk. 

(11 

11) 

Modified  milk. 

(11 

13) 

Modified  nnlk. 

( 

DHART  4. 

Days  of  Life 

F 

107° 

106° 
105° 
104'- 
103° 
[02° 
101° 
100° 
99° 
98° 
97° 
96° 
95° 

IBO 
ITO 
140 
130 
120 

no 

100 

90 
80 
70 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

c 

tie" 

41  1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

57.7° 

37.2° 
37.0° 
36  6° 

55.1° 

35,5° 

35  0? 

"  " 

M  K 

M  H 

*"' 

U  K 

Mi 

U  B 

X  s 

KI 

H  I 

UTE 

H  E 

ME 

/ 

/ 

V 

L 

\ 

/ 

/ 

/ 

/ 

\ 

./ 

^ 

/ 

^ 

^ 

r' 

^ 

1/ 

y 

7 

... 

-- 

-- 

V. 

... 

-- 

_.. 

-- 

V. 

u6 

1/ 

^ 

\ 

L 

L 

L_ 

~ 

A 

y 

v^ 

\ 

A 

,» 

A 

A 

A 

/ 

0 

\ 

\ 

^ 

/. 

V 

^ 

— 

'  1 

y 

y 

\/ 

V 

' 

\^ 

\ 

L 





__ 

_. 

__. 

__ 



-^ 

__ 

__ 

Infants  Avho  weigh  less  than  1200  grammes  at  birth  rarely  live,  even 
with  incubator  treatment  and  breast-milk  as  food.  Oberworth' found  only 
seven  cases  in  medical  literature  of  infants  weighing  less  than  910  grammes 


266 


'EDTATRK'S. 


(2  pounds)  Avlio  lived  for  periods  vuryiny  from  11  days  to  11  years.  Ex- 
posure to  cold,  even  for  a  short  time,  is  dangerous.  If  the  rectal  tempera- 
ture drops  below  93°  to  94°  F.,  or  if  it  rises  to  103°  or  104°  F.,  without  a 
remediable  cause,  the  chances  of  life  are  greatly  diminished. 

The  question  is  often  asked  whether  premature  infants,  even  if  their 
lives  are  saved,  can  eventually  be  as  well  developed  physically  and  men- 
tally as  are  those  born  at  term.  In  our  experience  there  seems  to  be  no 
question  that  when  once  we  have  succeeded  in  making  the  infant  gain 
steadily  in  weight,  and  assume  the  appearance  of  an  infant  at  term,  its. 
subsequent  condition  differs  in  no  respect  from  that  of  infants  born  at 
term.  Fig.  65  illustrates  the  wisdom  of  doing  all  in  our  power  to  save  the 
lives  of  these  infants. 


Infant  premature  at  30  weeks.    Birth- weight,  2040  grammes  {414:  pounds.)    Treated  in  incubator  64  days. 
Age,  9  months  ;  weight,  8400  grammes  (17>^  pounds.) 


The  pictui'e  was  taken  when  the  infant  was  nine  months  old  and  weighed  8400 
grammes  (17^-  pounds).  As  its  birth-weight  was  2040  grammes  (about  4^-  pounds),  it 
will  be  seen  that  its  weight  had  quadrupled.  He  was  fed  entirely  on  modified  milk 
from  the  laboratory  during  the  fu'st  year,  and  was  a  fine  large  boy,  walking  and  talking 
at  two  years  of  age.  He  was  perfectly  healthy  and  well  developed  b(jth  physically  and 
mentally. 


PREMATURE    LXFAXTS.  267 

His  sister,  who  was  premature  at  the  twenty-eighth  week,  was  eight  years  old. 
She  was  well  developed  and  strong,  and  was  unusually  bright  and  intelligent  for  her 
age.  She  was,  in  fact,  decidedly  in  advance  mentally  of  the  other  children  of  her  age 
at  school. 

Table  55  records  the  details  of  an  infant's  life  in  an  incubator  during  a 
period  of  sixty-four  days.  This  record  illustrates  what  emergencies  are 
likely  to  arise  and  how  they  can  be  met.  The  infant,  as  can  be  seen  by 
referring  to  the  columns  of  remarks,  came  very  near  dying  a  number  of 
times,  and  uncpestionably  would  have  died  had  it  not  been  carefully  man- 
aged, as,  for  example,  by  tlie  administration  of  oxygen,  by  prompt  changes 
in  its  food,  by  the  regulation  of  the  temperature  of  the  incubator,  and  by 
the  constant  attention  of  a  day  nurse  and  a  night  nurse. 


DIVISION    V. 

DISEASES    OF    THE    NEW-BORN. 


Before  entering  into  a  description  of  the  individual  diseases  of  the 
new-born,  it  will  be  profitable  first  to  consider  some  of  the  general  aspects 
of  disease  as  it  occurs  in  early  life. 

Disease  in  General. — The  peculiarities  which  characterize  disease  in 
children  are  mostly  limited  to  the  period  of  infancy  and  the  early  and 
middle  periods  of  childhood.  In  later  childhood,  that  is,  after  the  eighth 
or  ninth  year,  disease,  both  in  its  etiology,  pathology,  symptoms,  and  prog- 
nosis, resembles  closely  that  which  is  met  with  in  adult  life. 

In  the  earlier  periods  of  life,  on  the  contrary,  we  meet  with  distinct 
differences,  depending  partly  on  the  great  role  which  congenital  diseases 
pky  in  the  various  stages  of  development  and  partly  on  the  greater  vul- 
nerability of  the  growing  tissues  and  their  lessened  power  of  resistance 
not  only  to  the  known  specific  infections  but  to  numberless  as  yet  undif- 
ferentiated varieties  of  pathogenic  micro-organisms,  which  are  as  yet  but 
little  understood. 

Inheritance. — A  very  important  element  to  be  taken  into  considera- 
tion as  influencing  the  tendency  to  disease  is  inheritance.  The  occurrence 
in  the  parents  of  such  diseases  as  tuberculosis,  rheumatism,  and  the  various 
neuroses  seems  to  render  the  tissues  of  the  children  not  only  more  recep- 
tive to  these  conditions  but  to  so  vitiate  them  that  they  are  readily  affected 
by  many  other  diseases.  The  direct  inheritance  of  such  diseases  as  syph- 
ilis and  the  great  mortality  arising  from  them  are  distinctly  characteristic 
of  disease  in  infancy. 

Malformation. — The  greater  number  of  diseases  and  the  greater  ten- 
dency to  disease  in  early  life,  as  compared  with  a  later  period,  is  caused  in 
large  measure  by  a  lack  of  normal  intra-uterine  development,  resulting 
in  malformations,  each  representing  a  disease  in  itself  and  each  having 
such  influence  on  the  tissues  in  general  that  they  become  abnormally  re- 
ceptive to  many  diseases.  These  malformations,  such  as  of  the  mouth, 
nose,  stomach,  and  intestines,  bladder,  and  rectum,  are  of  especial  signifi- 
cance from  a  surgical  point  of  view,  Avhile  those  which  are  of  especial 
interest  to  us  medically  are  malformations  of  the  heart  and  brain  and  such 
conditions  of  arrested  development  as  are  represented  by  atelectasis. 

Traumatism. — A  class  of  diseases  distinctly  infantile  is  caused  by 
trauma,  such  as  certain  forms  of  meningeal  hemorrhages  and  abrasions 
268 


DISEASES    OF    THE    NEW-BORN.  2«9 

occurring  during  delivery,  which  afford,  as  in  the  case  of  an  unhealed 
umbilicus,  a  ready  entrance  for  the  micro-organisms  of  tetanus  and  of 
erysipelas.  The  various  forms  of  ophthalmia  neonatorum  must  be  in- 
cluded in  this  class  of  affections. 

General  Etiology. — In  addition  to  the  congenital  causes  of  infantile 
disease  just  enumerated  the  etiology  of  the  acquired  diseases  of  early  life 
is  of  great  interest  and  importance,  for  there  is  no  doubt  that  most  of  the 
diseases  of  early  life  are  the  direct  result  of  the  ignorance  or  neglect  of 
those  who  ha.ve  the  charge  and  direction  of  infants  during  this  period. 
The  chief  etiological  factors  of  disease  in  infancy  are  improper  food  and 
unhygienic  surroundings.  These  conditions  may  cause  such  specific  dis- 
eases of  nutrition  as  rhachitis,  scorbutus,  and  infantile  atrophy,  or  may 
result  in  such  a  marked  degree  of  malnutrition  that  there  is  a  decided 
predisposition  to  various  acute  diseases  such  as  those  of  the  gastro-enteric 
tract  and  of  the  lung,  and,  later  to  such  neuroses  as  chorea  and  many 
functional  disturbances. 

General  Pathological  Anatomy. — The  pathological  processes  which 
occur  in  early  life,  as  distinctive  from  a  later  period,  are  essentially  acute, 
the  chronic  morbid  processes,  except  those  which  result  from  acute  dis- 
ease, being  rare.  Hyperplasia  of  the  lymph-nodes  and  their  susceptibility 
to  infection  of  all  kinds,  together  with  their  great  activity  in  carrying  infec- 
tion, are  a  characteristic  feature  of  infantile  pathology. 

A  series  of  726  consecutive  autopsies  made  at  the  New  York  Infant 
Asylum  and  tabulated  by  Holt,  shows  the  relative  pathology  of  the  differ- 
ent organs.  None  of  these  autopsies  were  under  one  month,  72  per 
cent,  were  under  one  year,  and  only  3  per  cent,  were  over  two  years. 

According  to  these  figures  the  lungs  first  and  the  intestine  second 
were  found  affected  in  the  greatest  number  of  cases,  and  it  was  noted 
that  it  was  rare  to  find  the  lungs  normal  after  any  acute  infectious  disease 
had  lasted  a  week.  Out  of  the  above-mentioned  726  cases,  pathological 
conditions  were  found  in  the  lung  in  399  cases  ;  of  these,  322  were  cases 
of  pneumonia,  of  which  139  were  primary  and  56  were  tuberculous. 
There  were  6  cases  of  congenital  atelectasis,  1  case  of  serous  pleurisy,  5 
cases  of  empyema,  and  although  there  was  dry  pleurisy  in  nearly  all  the 
severe  cases  of  pneumonia,  there  was  no  case  of  pleurisy  uncomplicated 
by  disease  of  the  lung.  The  gastro-enteriG  tract  was  affected  in  189  cases  ; 
of  these,  116  cases  were  acute  ileo-colitis  with  or  without  gastritis.  There 
were  no  cases  of  gastritis  without  intestinal  lesions.  There  were  72  cases 
of  acute  diarrhoea  without  gross  lesions.  There  was  one  case  of  intussus- 
ception. The  brain  and  meninges  were  affected  in  35  cases,  of  which  11 
were  tubercular  meningitis.  There  were  26  cases  of  malnutrition  without 
gross  lesions.  The  kidneys  were  affected  in  26  cases,  7  of  which  were  mal- 
formations, and  only  5  cases  were  primary.  The  heart  was  affected  in  6 
cases ;  of  these,  3  were  congenital  malformations,  3  were  pericarditis,  all 
occurring  in  cases  of  pneumonia,  and  there  were  no  cases  of  acute  or 


270  PEDIATRICS. 

chronic  endocarditis.     The  pentoneum  was  affected  in  four  cases.     The 
mouth  was  affected  in  one  case  (noma). 

It  thns  appears  that  pathological  conditions  of  the  liver  and  spleen  are 
rare  in  early  life,  as  are  primary  disease  of  the  kidneys  and  organic  disease 
of  the  brain  itself.  New  growths  are  rare,  and,  when  present,  are  usually 
of  the  kidney  or  bones.  Diseases  of  the  bones  and  joints  are  very  com- 
mon, and  are  usually  tubercular  or  syphilitic,  more  commonly  the  former. 
Diseases  of  nutrition  are  extremely  common. 

General  Symptoms. — The  clinical  picture  of  disease  in  older  children 
does  not  present  many  features  different  from  what  is  seen  in  the  adult. 
In  infancy  and  early  childhood,  however,  there  are  many  differences. 
The  infant  cannot  express  its  thoughts  and  sensations  in  words,  and  in 
place  of  this  indicates  its  discomfort  by  cries  and  various  movements. 
In  addition  to  this,  tlie  nervous  system  is  in  so  sensitive  a  condition  and 
in  such  unstable  equilDDrium  that  its  manifestations  in  disease  are  very 
misleading.  In  disease  of  the  lung,  for  instance,  the  young  child  is  very 
apt  to  locate  its  discomfort  in  the  abdomen,  while  gastric  distention  may 
be  symptomatically  represented  by  marked  pulmonary  symptoms.  Cere- 
bral symptoms  whicli  would  at  a  later  period  point  towards  organic 
lesions  of  the  brain  or  its  meninges,  often  in  early  life  simply  indicate  a 
disturbance  of  the  meningeal  circulation  which  may  arise  in  almost  any 
disease  with  a  heightened  temperature  or  with  interference  with  the  circuT 
lation,  as  in  pertussis,  in  cardiac  disturl^ance,  and  in  acute  gastro-enteric 
disease.  The  reverse  of  this  picture  is  at  times  seen  in  cases  of  consider- 
able pleuritic  effusion  \\\i\\  displacement  of  the  heart,  in  which  very  slight 
rational  signs,  in  comparison  with  the  same  condition  in  adults,  are  shown, 
the  child  appearing  fairly  well  and  inclined  to  run  about  its  nursery. 
Agam,  with  very  slight  lesions  in  the  lungs,  most  violent  pulmonary 
symptoms  may  arise.  An  insignificant  disturbance  of  digestion  may  pre- 
sent most  alarming  symptoms  of  pallor  and  collapse.  Infants  and  young 
children  may,  from  purely  nervous  causes,  vomit  so  continuously  that  the 
symptoms,  when  the  vomiting  has  ceased,  closely  simulate  a  typhoid  con- 
dition, and,  still  more  frequently,  tubercular  meningitis. 

The  prodromal  symptoms  of  luany  diseases,  both  benign  and  malig- 
nant, simulate  each  other  so  closely  in  early  life  that  the  diagnosis  must 
often  be  left  in  abeyance  for  many  days  longer  than  would  be  necessary 
at  a  later  period.  Pulmonary,  gastro-enteric,  and  cerebral  diseases  fre- 
quently shoAv  this  correspondence  of  symptoms.  Affections  of  the  ear, 
where  the  aural  symptoms  are  marked,  as  they  often  are,  produce  a  great 
variety  of  symptoms  pointing  towards  other  organs,  such  as  cough  and 
vomiting,  and  owdng  to  the  late  closure  of  the  petrosquamosal  suture,  the 
most  pronounced  cerebral  symptoms.  The  rational  indications  of  a  dis- 
ease, therefore,  in  early  life  are  a  symptom-complex,  and  we  have  to  rely 
almost  entirely  on  our  pliysical  examination.  It  must  be  remembered, 
however,  that  seemingly  grave  and  alarming  symptoms   do    not  neces- 


DISEASES   OF   THE    NEW-BORN.  271 

sarily  indicate  a  serious  disease,  while  mild  and  unobtrusive  symptoms 
may  be  the  beginning  of  a  fatal  disease. 

Of  especial  importance  in  infantile  symptomatology  are  the  cry,  the 
facial  expression,  the  posture,  and  the  movements  of  the  body  ;  these 
will  be  described  Avhen  the  various  diseases  are  spoken  of. 

General  Diagnosis. — It  has  already  been  stated  that  the  diagnosis  in 
children  is  most  satisfactorily  made  by  the  physical  signs,  but  the  examina- 
tion is  often  so  difficult  to  obtain  that  we  necessarily  also  depend  greatly 
on  the  history  given  by  the  parents  and  on  inspection.  There  are,  how- 
ever, certain  methods  of  examination  which  are  preferable  to  others  and 
which  differ  in  their  system  from  those  which  we  employ  in  adults.  The 
employment  of  these  methods,  though  involving  more  time,  render  it 
possible  to  obtain  a  satisfactory  examination  in  almost  every  case. 

General  Prognosis. — The  mortality  in  early  life  is  greater  in  inverse 
proportion  to  the  age,  so  that  the  prognosis  in  diseases  which  in  older 
children  would  be  regarded  as  benign  should  in  the  early  weeks  and 
months  of  life  be  considered  as  serious,  and  the  prognosis  should  be  cor- 
respondingly grave.  On  the  other  hand,  certain  organic  diseases,  such  as 
those  of  the  kidney  and  heart,  which  would  be  attended  with  a  very  bad 
prognosis  in  later  life,  in  childhood  are  much  more  likely  to  recover,  on 
account  of  the  wonderful  recuperative  powers  of  children  due  to  their 
rapid  reconstructive  metabolism. 

Young  children  may  die  after  a  few  hours'  illness  apparently  from  their 
lack  of  power  to  resist  the  onset  of  various  infections,  such  as  scarlet  fever 
and  pneumonia,  before  these  diseases  have  declared  themselves  by  their 
characteristic  symptoms.  Sudden  death  from  various  and  obscure  causes 
is  also  not  very  uncommon  in  weak  infants  who  are  suffering  from  mal- 
nutrition. Internal  hemorrhages,  as  in  Buhl's  disease,  asphyxia  from 
many  causes,  sudden  collapse  in  the  course  of  pertussis,  laryngospasm, 
or  cardiac  disease,  may  also  be  the  cause  of  sudden  death. 

Maternal  Impressions. — A  few  words  should  be  said  concerning  the 
subject  of  maternal  impressions.  For  many  years  there  has  been  accumu- 
lating a  considerable  amount  of  evidence  shomng  that  a  violent  mental 
impression  made  upon  a  woman  who  is  at  the  time  carrying  a  child  may 
be  followed  by  a  physical  or  mental  defect  in  the  child  which  bears  a 
striking  relation  in  character  to  the  impression  made  upon  the  mother. 
Thus,  Sir  Walter  Scott  narrates  that  King  James  the  First  could  not  endure 
the  sight  of  a  drawn  sword.  This  feeling  had  been  attributed  by  those 
who  believe  in  maternal  impressions  to  the  terror  which  his  mother  ex- 
perienced at  witnessing  the  murder  of  Rizzio.  Still  more  numerous  are 
the  facts  adduced  to  prove  that  bodily  defects,  such  as  harelip,  club-foot, 
and  hairy  mole,  may  be  caused  by  strong  impressions  of  pain  or  terror 
experienced  by  the  mother  at  the  time  wiien  the  foetus  is  in  a  certain 
stage  of  intra-uterine  development.  Interesting  as  these  instances  are,  it 
is  the  general  belief  that  nothing  more  has  been  proved  than  that  they 


272  PEDIATRICS. 

depend  upon  a  coincidence.  The  final  decision  on  this  obscure  subject 
must  rest  on  future  investigation,  and  until  something  more  definite  is 
known  we  should  guard  a  woman  during  her  pregnancy  from  all  unpleas- 
ant impressions  with  far  more  care  than  Ave  do  at  present. 

The  diseases  Avhich  we  speak  of  as  diseases  of  the  new-born  are  distinct 
from  those  which  are  acquired  later  in  life,  in  that  they  represent  in  almost 
every  case  an  arrest  of  the  normal  development  which  should  occur  during 
intra-uterine  life.  A  stage  of  development  which  is  normal  at  a  certain 
period  of  intra-uterine  life  becomes  abnormal  if  it  persists  to  a  later 
period,  and  this  persistence  of  an  early  stage  of  development  constitutes 
in  the  great  majority  of  cases  what  is  known  as  congenital  malformation, 
Such  a  failure  of  development  may  be  the  result  of  intra-uterine  inflam- 
mation, which,  either  by  crippling  the  various  functions  or  by  arresting 
the  normal  intra-uterine  growth,  produces  a  condition  of  disease  -at  birth. 
In  many  cases,  however,  the  causes  are  so  obscure  as  to  elude  our  usual 
methods  of  examination.  Diseases  of  the  new-born  may  also  be  made  to 
include  certain  abnormal  conditions  which  arise  immediately  after  birth  or 
in  the  early  days  of  life. 

Although  many  of  these  affections  must  pass  into  the  hands  of  the 
surgeon  for  treatment,  yet  it  is  very  important  for  the  medical  practitioner 
to  be  able  to  recognize  at  once  their  true  nature  and  their  significance. 
For  purposes  of  simplicity,  these  diseases  can  be  classified  into  diseases  of 
the  head,  diseases  of  the  neck,  diseases  of  the  trunk,  diseases  of  the  extremities, 
and  general  diseases. 

DISEASES   OF   THE   HEAD. 

Caput  Succedaneum. — The  normal  average  head  at  birtli  may  be 
misshapen    from  various   causes.     Of   the  conditions  Avhich   may  cause 

unusual  appearances,  the  most  common  is 
Fig.  66.  called  capid  succedaneum,  a  case  of  which  is 

represented  in  Fig.  QQ. 

This  infant,  a  male,  two  hours  old,  presented 
a  swelling  over  the  right  parietal  hone  extending 
hack  to  the  occiput,  causing  an  irregular  tumor 
and  ;i  great  increase  in  the  anteroposterior  diam- 
eter (it  the  head.  The  tumor  did  not  fluctuate. 
The  presentation  was  occiput  left  anterior,  and 
no  instruments  v/ere  used.  The  swelling  corre- 
sponded to  the  place  where  there  was  the  least 
pressure,- — that  is,  the  presenting  part. 

It  is  needless  to  say  that  this  caput  suc- 
caput  succedaneum.  Male.  2  hours       ccdaueum    rcquircs    uo    treatment,    as    it- 

gradually  disappears  of  itself  by  absorp- 
tion in  a  few  days.  It  is  simply  a  swelling  of  the  scalp  caused  by  a 
passive  congestion  with  extravasation  of  blood  and  lymph  into  the 
connective  tissue  external  to  the  pericranium. 


DISEASES   OF   THE   KEW-BORN. 


273 


Fig.  67. 


Caput  sLiccedaneum  must  be  carefully  distinguished  from  another 
swelling  of  the  scalp,  cephalhcematoma,  which  may  occur  in  connection 
with  it,  and  which  appears  as  the  caput  succedaneum  disappears. 

Cephalhaematoma. — During  labor  a  hemorrhage  may  take  place  from 
the  blood-vessels  of  the  head  which  gives  rise  to  a  tumor  m  one  of  three 
situations.:  (1)  between  the  occipito-frontalis  aponeurosis  and  the  perios- 
teum ;  (2)  between  the  periosteum  and  the  skull ;  or  (3)  between  the 
skull  and  the  dura  mater.  The  first  two  are  known  as  external  cephal- 
hcematoma,  the  last  as  internal  cephalhcematoma.  The  cause  cannot  be  en- 
tirely from  pressure  over  the  presenting  part,  as  the  lesions  have  been 
found  in  breech  presentations. 

Cephalhaematoma  is  distinguished  from  caput  succedaneum  by  its  sharp 
limitation  to  one  of  the  parietal  bones,  by  its  fluctuation,  and,  if  seen  late,  by 
its  surrounding  bony  wall.  Cephalhasmatoma  usually  develops  after  birth,' 
while  caput  succedaneum  is  present  at  birth.  It  can  be  diagnosticated  posi- 
tively by  the  withdrawal  of  some  of  the  fluid  by  a  hypodermic  syringe. 
Another  condition  which  may  simulate  it  somewhat  is  a  depressed  fracture. 
The  differential  diagnosis  from  this  latter  condition  can  best  be  made  by 
remembering  the  fact  that  the  resistant  rim  of  the  cephalhaematoma  is 
raised  above  the  level  of  the  surrounding 
bone,  and  is  somewhat  compressible,  while 
on  the  inside  it  can  be  felt  to  slope  evenly 
towards  a  fluctuating  centre.  In  fracture 
no  such  arrangement  occurs. 

(a)  External  Cephalhcematoma. — By  far 
the  most  common  form  is  that  in  which 
the  tumor  has  formed  between  the  skull 
and  the  periosteum.  It  shows  itself  as  an 
irregular  circular  swelling  over  a  parietal 
bone,  and  gives  on  palpation  a  distinct 
feeling  of  fluctuation.  The  skin  over  it  is 
not  discolored  or  reddened.  In  the  cases 
that  have  existed  for  a  few  days  a  bony 
wall  can  be  felt  surrounding  the  tumor, 
the  edges  of  which  give  a  crackling  sensa- 
tion under  the  finger.  In  this  stage  it 
may  strongly  suggest  a  fluid  tumor  coming 
through  a  circular  hole  in  the  skull. 

Fig.  67  represents  a  case  of  double  cephalhaematoma  of  the  external  variety  ;  that 
is,  it  is  an  extravasation  of  blood  under  the  pericranium.  Its  base  corresponded  to 
the  denuded  bone,  and  was  oval  or  circular.  There  were  bulging  tumors  on  each  side 
of  the  sagittal  suture  with  a  deep  sulcus  between  them. 

Treatment. — Treatment  designed  to  promote   absorption   should  be 

avoided.     The  part  should  be  protected  from  injury.     Al3sorption  usually 

occurs  in  the  course  of  a  few  weeks. 

18 


Double  cephalhsematoma.   Infant,  4  days 
old. 


274 


PEDIATRICS. 

Fig.  68. 


Double  external  cephalheematoma.    Both  parietal  bones.    Warren  Museum,  Harvard  University. 

Fig.  69. 


External  cephalhsematoma.    Parietal  bone  dissected.    Warren  Museum,  Harvard  University. 


DISEASES    OF    THE   NEW-BOKX.  275 

Fig.  68  represents  the  dried  preparation  of  a  double  cephalhsema- 
toma  which  is  in  the  Warren  Museum. 

On  the  left  side  of  the  skull  (the  right  side  of  the  picture)  the  integu- 
ment has  been  nearly  removed,  showing  a  raised  bony  rim. 

On  the  right  side  of  the  skull  (the  left  side  of  the  picture)  the  integu- 
ment has  been  cut  off  and  partially  deflected,  showing  the  cavity  which 
contained  the  diffused  blood. 

Fig.  69  is  a  parietal  bone  dissected  so  as  to  show  the  condition  of 
the  bone  in  a  case  of  external  cephalhternatoma. 

The  specmien  shows  well  the  raised  rim  and  the  porous  condition  of 
the  bone  underlying  the  tumor.  In  two  or  three  places  the  bone  sub- 
stance has  entirely  disappeared. 

(6)  Internal  Cephalhcemoioma. — Internal  cephalliEematoma  is  situated 
between  the  inner  surface  of  the  skull  and  the  dura  mater,  and  is  rare. 
It  is  at  tunes  found  in  connection  with  the  external  variety. 

The  prognosis  m  these  cases  is  bad.  They  are  usually  fatal,  and  there 
is  no  known  treatment  which  can  save  them. 

Mening-ocele. — By  the  term  meningocele  is  understood  a  protrusion 
of  some  part  of  the  membranes  of  the  brain  through  a  hole  left  in  the 
cranial  wall  by  defective  ossification.  In  some  instances  this  is  caused  by 
an  intra-uterine  hydrocephalus.  These  tumors  generally  contain  some 
of  the  cerebro-spinal  fluid  in  the  bag  of  membrane.  Such  fluid  can  often 
be  reduced  into  the  skull  by  gentle  pressure,  but  at  the  risk  of  bringing  on 
symptoms  of  cerebral  disturbance,  an  important  point  iu  differentiating 
the  condition  from  cephalhcematoma. 

Fig.  70  represents  a  small  meningocele  above  the  left  ear  about  2.5  cm.  (1  inch) 
in  diameter.     Some  fluid  was  withdrawn  from  it  by  an  aspirating  needle,  and  the  con- 
tents of  the  sac  proved  to  be  serous  without  cells.     The  sac  refilled  after  tapping.     No 
more  extensive  operation  on  it  has  so  far  been  undertaken.     The  child  was  rhachitic. 
It  had  a  fall  some  time  previous  and  struck  its  head.     Nothing  abnormal  was  noticed 
about  the  child  previous  to  the  fall,  but  after  the  ac- 
cident a  swelling  appeared  above  and  behind  the  ear.  Fig.  70. 
The  sAvelling  increased  in  size  when  the  child  cried,      \~      "^IH^  \ 
was  soft,  fluctuating,  and  not  tender.     The  knee-jerks     \            ^^^^^^^Bi' 
and  sensation  were    normal.      The  ophthalmoscopic                       ^I^^^^^K 
examination  disclosed  nothinff  abnormal.                                              ^  ^^^^^^B 

A  much  more  serious  condition  is  shown  '^IH 

in  the  meningocele  in  the  following  case.  \  _f^M 

The  infant  was  two   weeks    old  when    operated  B 

upon.     Behind  its  left  ear  was   an   irregular  tumor     \  ^ 

about  7.5  cm.  (3  inches)   long.      The   ear  was  pushed  Meningocele.    Female,  S  years 

forward,  and  appeared  to  be  growing  from  the  tumor.  old. 

The  labor  was  normal,   and  the  infant  at  birth  was 

perfectly  healthy  and  well  formed,  except  for  the  tumor,  which  was  congenital.  On 
examination  the  tumor  was  found  to  be  fluctuating  and  translucent.  There  were  large 
veins  on  its  surface.     No  impulse  could  be  felt  on  crying,  nor  did  pressure  cause  any 


276  PEDIATRICS. 

cerebral  symploms.  On  aspirating  it,  45  c.c.  (1^  ounces)  of  a  clear  reddish  fluid  were 
withdrawn.  This  fluid  contained  red  blood-corpuscles  and  a  few  endotheUal  cells.  No 
unfavorable  symjitoms  followed  the  aspiration.  After  the  withdrawal  of  the  fluid  two 
openings  could  l)e  felt,  the  anterior  of  which  probably  connected  with  the  external  audi- 
tory meatus.  The  tumor  was  increasing  in  size  so  rapidly  that  an  operation  was  decided 
upon.  On  removing  it  an  opening  in  the  skull  large  enough  to  admit  two  fingers  was 
found.  The  child  made  a  rapid  recovery  from  the  operation,  and  was  left  with  only  a 
scar  behind  the  ear.  There  were  no  cerebral  symptoms.  During  convalescence  the 
child  seemed  to  be  mentally  bright. 

Encephalocele. — Still  more  common  than  the  pure  meningocele  is 
that  condition  in  which  the  hernia  contains  some  of  the  cerebral  sub- 
stance as  well  as  the  membranes.  This  condition  is  called  encephalocele  ; 
or  if,  as  is  often  the  case,  it  contains  a  portion  of  a  dilated  ventricle,  so  that 
the  tumor  is  filled  with  cerebro-spinal  fluid,  it  is  known  as  hydro-encepha- 
locele  or  as  hydro-encephalo-meningocele. 

Fig.  71  represents  a  remarkable  case  of  hydro-encephalocele  which 
was  treated  by  Dr.  Lovett  in  the  hospital. 

The  infant  from  the  time  of  its  birth  had  tonic  and  clonic  convulsions,  occurring 
usually  as  often  as  once  in  three  hours.  It  was  brought  to  the  hospital  when  it  was 
two  months  old.  It  was  well  formed  in  every  way,  except  that  it  had  a  tumor  on  the 
back  of  its  head  which  was  at  least  one-third  as  large  as  its  skull.  The  tumor  was 
only  partly  covered  with  skin,  the  upper  part  of  it  being  a  thin  translucent  membrane. 
It  communicated  with  the  brain  through  a  large  square  hole  in  the  back  of  the  skull. 
The  tumor  fluctuated  slightly  and  appeared  to  be  a  multilocular  cyst,  for  when  it  was 
aspirated  only  a  part  of  the  contained  fluid  could  be  withdrawn.  The  tumor  was 
removed  by  Dr.  Lovett  and  the  wound  sewed  up  tightly.  The  cyst  was  found  to  con- 
tain a  viscous  fluid  with  slight  flakes  in  it  which  proved  to  be  particles  of  cerebral 
substance.  The  convulsions  immediately  became  less  frequent,  and  ultimately  on 
treatment  with  bromide  of  potash  disappeared  almost  entirely. 

The  infant  in  other  respects  was  very  little  affected  by  the  operation,  and  recov- 
"ered  rapidly.  After  remaining  in  the  hospital  two  weeks  it  was  taken  to  its  home, 
where  it  died  some  months  later  of  some  intercurrent  affection. 

Regarding  these  tumors  in  general,  it  is  enough  to  say  that  we  should 
view  with  suspicion  any  fluctuating  swelling  that  seems  to  have  a  deep 
attachment  in  the  neighborhood  of  one  of  the  cranial  sutures.  The  most 
frequent  seat  of  these  tumors  is  in  the  occipital  region  and  at  the  root  of 
the  nose.  Their  treatment  has  not  proved  very  successful.  Some  few 
may  steadily  decrease  of  themselves  and  ossification  may  block  up  the 
abnormal  opening.  Pressure  and  the  injection  of  Morton's  fluid  have 
both  been  tried,  and  in  some  cases  have  been  attended  with  success. 
At  present  the  operative  plan  of  treatment  is  considered  the  best.  With- 
out interference  the  tendency  is  usually  towards  rupture  of  the  hernia, 
convulsions,  and  death. 

Anencephalia. — The  cerebro-spinal  system  is  formed  from  the  medul- 
lary tube,  which  is  made  by  the  infolding  of  epiblast  along  the  medullary 
groove :  if  the  formation  of  the  medullary  tube  is  for  any  reason  incom- 
plete, or  if  the  dorsal  wall  of  the  tube  is  destroyed,  the  cerebrum  or  part 


DISEASES   OF   THE   NEW-BORN. 


277 


of  the  cerebral  axis  will  remain  rudimentary.  According  to  the  amount 
of  interference  with  the  development  we  may  fmd  more  or  less  of  the 
brain  remaining  in  a  rudimentary  condition,  and  thus  producing  greater 
or  less  degrees  of  what  is  called  anencephalia.  Total  anencephalia  is 
rare.  Partial  anencephalia  is  much  more  common.  These  cases  are  not 
of  especial  interest,  as  it  is  exceptional  for  them  to  live  beyond  a  few  days. 
Cong-enital  Hydrocephalus. — One  of  the  more  common  malforma- 
tions of  the  head  is  a  hydrocephalic  condition  at  birth,  called  congenital 
hydrocephalus.     It  is  described  on  page  970. 

Fig.  71. 


Female,  2  months  old.    Hydro-encephalocele. 


Harelip. — If  the  maxillary  process  on  one  or  both  sides  of  the  face 
fails  to  unite  with  the  intermaxillarj^  process,  a  cleft  will  remain  open  in 
the  contour  of  the  upper  lip  on  one  or  both  sides  of  the  intermaxillary 
bone,  and  hence  we  shall  have  single  or  double  harelip  as  the  case  may 
be.  If  the  cleft  extends  the  whole  distance  from  mouth  to  nostril  it  is 
called  complete,  but  if  the  nostril  is  not  reached  by  the  opening  it  is  called 
partial  harelip.  If  there  is  a  failure  of  the  palatine  processes  to  join,  one 
or  both  nostrils  will  open  into  the  roof  of  the  mouth  as  well  as  into  the 


278  PEDIATRICS. 

pharynx,  and  we  sliall  have  tlie  malformation  knoAvn  as  cleft  palate- 
This  may  be  a  large  Chasm  running  the  whole  length  of  the  roof  of  the 
mouth,  or  may  be  only  a  small  opening,  or  nothing  but  a  bifurcation 
of  the  tip  of  the  uvula  may  be  left  to  show  that  the  normal  process  of 
development  has  not  gone  on  to  completion. 

Besides  their  unsightly  appearance, 
^^^-  ' '"■  which  always  causes  the  mother  great 

concern,  these  malformations  may  so 
interfere  with  the  infant's  taking  the 
breast  as  to  render  sucking  impossible 
and  make  it  necessary  to  feed  the  in- 
fant with  a  spoon. 


Double  harelip. 


Fig.  72  represents   a  typical  case  of  dou- 
ble harelip  uncomplieated  by  cleft  palate. 

The  intermaxillary  bone  was  of  a  large 
size,  protruded  considerably  beyond  the  mar- 
gin of  the  lips,  and  was  somewhat  twisted 
upon  itself.  This  alteration  of  the  position 
of  the  intermaxillary  bone  may  cause  the  teeth  that  grow  from  it  to  appear  in  very 
unusual  places,  so  as  to  protrude,  for  instance,  from  the  nostril. 

The  operation  should  be  performed  during  the  early  weeks  of  life, 
as  the  growth  of  the  facial  muscles  is  not  then  sufficient  to  interfere  with 
the  healing  of  the  wound. 

There  is  considerable  difference  of  opinion  as  to  when  cases  of  con- 
genital harelip  should  be  operated  on.  In  general,  it  can  be  said  that 
cases  of  single  harelip  unassociated  with  cleft  palate  can  be  operated  on 
from  three  to  six  weeks  after  birth,  while  the  severer  forms  are  best  left 
for  as  many  months.  When  the  infant  is  wasted  and  is  in  a  poor  general 
condition,  the  indication  is  to  postpone  the  operation,  as  it  is  seldom 
that  this  defect  is  the  cause  of  the  general  lack  of  proper  development.  If 
harelip  is  associated  with  cleft  palate,  the  latter  condition  should  be 
operated  upon  before  attempting  to  correct  the  deformity  of  the  lip. 

Cleft  Palate. — In  speaking  of  harelip  most  of  the  conditions  occurring 
in  cleft  palate  have  been  described.  The  difficulty  of  feeding,  if  the  cleft 
involves  the  hard  as  well  as  the  soft  palate,  is  very  great,  and  can  best  be 
accomplished  with  a  spoon.  The  difficulty  in  articulation  and  the  un- 
pleasant sound  of  the  voice  are  reasons  which  lead  the  parents  to  demand 
early  treatment.  We  should  operate  as  early  as  the  infant's  condition 
permits,  usually  before  the  third  month,  and  before  the  sixth  month  at  all 
events.  The  operation  for  cleft  of  the  soft  palate  is  called  staphylorrhaphy, 
and  that  for  the  closure  of  a  cleft  in  the  hard  palate  is  termed  uranoplasty. 
The  larger  the  opening  in  the  palate  the  more  successful  will  be  the  treat- 
ment by  apparatus  in  comparison  with  that  by  the  knife,  and  many  prefer 
to  close  the  cleft  by  fitting  artificial  plates. 

Tongue-Tie. — In  quite  a  number  of  cases  the  frasnum  of  the  tongue  is 


DISEASES  OF  THE  NEW-BORN.  279 

abnormally  short  at  birth.  In  extreme  cases  the  tip  of  the  tongue  is  so 
closely  bomid  to  the  lower  jaw  that  it  cannot  be  protruded  beyond  the 
line  of  the  gum  or  touched  to  the  roof  of  the  mouth.  The  mother  usually 
notices  that  the  infant  does  not  nurse  readily,  and  brings  it  to  the  physi- 
cian to  discover  the  cause.  In  most  cases  on  passing  the  finger  into  its 
mouth  the  infant  is  found  to  suck  fairly  \vell ;  but  there  can  be  no  doubt 
that  this  condition,  which  is  called  tongue-tie,  mterferes  somewhat  with 
the  process  of  sucking. 

Children  who  have  not  learned  to  talk  at  the  usual  time  in  the  second 
and  third  years  are  frequently  brought  to  me  with  the  statement  that  they 
are  tongue-tied,  and  the  parents  wish  the  condition  to  be  treated.  Large 
numbers  of  children  are  taken  to  the  physician  under  this  supposition 
but  in  very  few  instances  are  they  tongue-tied.  These  children  belong  to 
the  class  of  retarded  speech.  The  condition  is  a  central  one  of  the 
brain,  and  not  a  local  one  in  the  mouth,  and  if  children  hear  well  and  are 
bright  and  mentally  well  developed,  even  though  they  do  not  speak  at  the 
third,  fourth  or  even  fifth  year,  as  a  rule  they  learn  to  speak  later. 

Treatment. — The  treatment  is  to  cut  the  frsenum.  This  operation 
should  be  followed  by  no  hemorrhage  and  rec{uires  no  dressing.  Having 
the  child's  head  held  in  a  fairly  good  light  by  an  assistant,  and  guarding 
the  lower  part  of  the  tongue  with  the  perforated  flange  of  a  director,  a 
small  cut  is  made  m  the  tense  frsenum  with  a  pair  of  blunt-pointed 
scissors.  By  making  the  cut  close  to  the  gum  there  is  no  danger  of 
wounding  the  ranine  artery.  The  cut  is  prolonged  as  far  as  is  necessary 
by  tearing  with  the  fmger-nail. 

Ranula. — Beneath  the  tongue  we  somethnes  find  the  mucous  mem- 
brane bulging  out  as  a  bluish,  translucent  tumor  which  is  soft,  painless, 
and  semi-fluctuating.  This  condition  is  called  ranula,  and  is  a  retention 
cyst  caused  by  the  blockmg  of  a  mucous  duct.  When  opened,  a  small 
amount  of  glauy  fluid  escapes,  but  the  collapse  of  the  walls  of  the  cyst 
brings  the  edges  of  the  cut  together  and  they  cjuickly  adhere.  The  fluid 
will  soon  re-collect ;  therefore  the  only  sure  way  of  dealing  with  these 
cysts  is  to  pinch  up  their  anterior  wall  with  fine  forceps,  and  with  the 
scissors  remove  so  much  of  it  as  to  leave  no  opportunity  for  the  edges  to 
adhere.  A  gentle  application  of  nitrate  of  silver  to  the  edges  and  interior 
of  the  sac  after  the  cut  has  been  made  with  the  scissors  materially  helps 
to  promote  the  cure.  It  is  not  common  in  new-born  children,  but  it 
occurs  often  enough  to  deserve  mention. 

Protrusion  of  the  Ears. — A  deformity  which  is  quite  frequent  at 
birth,  and  which  mcreases  as  the  infant  approaches  childhood,  is  the  pro- 
trusion of  the  ears.  The  ear,  besides  at  times  being  placed  in  an  irregular 
position  on  the  head,  has  in  these  cases  a  tendency  to  stand  out  from  the 
head  farther  than  is  considered  normal.  This  position  of  the  ear  usually 
annoys  a  mother  very  much,  and  the  physician  will  frequently  be  con- 
sulted as  to  the  means  by  which  the  deformity  may  be  rectified. 


280  PEDTATRirS. 

Treatment. — In  a  large  number  of  cases  the  persistent  application  of 
pressure  by  means  of  various  devices,  one  of  which  is  a  fenestrated  cap, 
will  cause  the  ears  to  be  flattened  against  the  side  of  the  head.  In  intract- 
able cases  an  operation  will  have  to  be  performed,  but  it  is  very  simple 
and  does  not  leave  an  unsightly  scar. 

Ophthalmia  Neonatorum. — Ophthalmia  neonatorum  has  been  divided 
into  two  forms,  the  catarrhal  and  the  purulent. 

(a)  Catarrhal  OpUhahnia. — The  catarrhal  form  may  be  caused  by  any 
slight  irritation  of  the  eyes  of  the  infant.  It  runs  a  very  mild  course,  the 
inflammation  attacking  chiefly  the  palpebral  conjunctiva.  Often  the  only 
symptoms  noticed  are  a  slight  photophobia  and  a  collection  of  the  secre- 
tion in  the  angles  of  the  lids  and  upon  their  borders.  Its  whole  course  is 
mild,  and  often  it  is  all  over  in  a  feAv  days. 

(6)  Purulent  Ophthalmia. — Although  a  considerable  number  of  causes 
for  purulent  ophthalmia  in  the  new-born  have  been  given,  such  as  trauma, 
exposure  to  light  and  cold,  and  others,  certainly  ninety-five  per  cent,  of 
all  cases  are  caused  by  infectious  material  from  the  genito-urinary  tract 
of  the  mother,  and  in  most  instances  by  gonorrhceal  pus.  The  early 
signs  of  the  disease  may  appear  at  any  time  from  the  third  hour  of  life, 
and  the  earlier  the  pus  appears  the  more  virulent  will  be  the  course  of 
the  disease  and  the  more  unfavorable  the  prognosis.  If  infection  takes 
place  during  the  birth  of  the  child,  the  symptoms  usually  begin  on  the 
third  day  ;  but,  as  contaminated  linen  and  fingers  may  carry  the  infectious 
material  to  the  infant's  eyes  at  a  later  period,  the  symptoms  may  be 
delayed  indefinitely. 

Symptoms. — The  disease  begins  as  a  redness  of  the  conjunctiva,  with 
a  slight  discharge  from  the  corner  of  the  eye.  This  is  succeeded  with 
startling  rapidity  by  intense  inflammation  of  the  lids.  In  twenty-four 
hours  the  upper  Kd  may  become  so  much  swollen  as  to  overhang  the 
cheek  and  render  opening  the  eye  impossDDle.  On  separating  the  lids,  a 
little  greenish  pus,  which  may  even  be  tinged  with  blood,  wells  up  between 
-them.  At  first  the  cornea  is  unaffected,  but  if  the  pus  accumulates  under 
the  oedematous  lids  it  soon  shows  signs  of  ulceration.  In  the  second 
twenty-four  hours  the  ulceration  may  perforate  the  cornea  and  evacuate 
the  aqueous  humor,  thus  bringing  the  iris  into  contact  with  the  posterior 
surface  of  the  cornea.  The  inflammation  may  extend  around  the  eye 
and  well  over  the  forehead  and  malar  prominence,  but  it  does  not  persist 
in  the  latter  region  very  long.  All  the  symptoms  disappear  slowly,  and 
recovery  takes  place,  except  in  those  cases  in  which  the  cornea  has  been 
permanently  injured  by  ulceration. 

Treatment. — In  treating  this  disease  we  must  be  very  prompt  and 
energetic.  It  often  may  be  averted  by  what  is  known  as  Crede's  method. 
This  consists  in  dropping  one  or  two  minims  of  a  two  per  cent,  solu- 
tion of  nitrate  of  silver  into  each  eye  of  the  new-born  infant.  As  even 
this  has  been  known  to   cause  a  considerable  amount  of  irritation,  a 


DISEASES    OF   THE    NEW-BORN.  281 

solution  of  protargol,  or  argyrol,  one  or  two  per  cent.,  is  now  used  in 
preference  to  the  silver  nitrate. 

After  the  disease  has  once  begun,  two  indications  must  be  kept  in 
mind:  (1)  to  reduce  the  inflammation,  and  (2)  to  prevent  the  pus  from 
accumulating  behind  the  tightly  closed  lids.  By  far  the  best  way  of  apply- 
ing cold  to  the  eye  is  by  compresses  of  thin,  soft  pieces  of  linen  cut  into 
small  squares.  Not  more  than  two  thicknesses  are  to  be  used  at  once. 
These  compresses  are  to  be  cooled  by  laying  them  on  a  piece  of  ice  or 
floating  them  in  ice-water.  They  must  be  constantly  changed.  To  re- 
move the  pus,  a  gentle  irrigation,  such  as  can  be  easily  obtained  by  using 
a  medicine  dropper,  is  sufficient. 

The  secretion  is  highly  contagious,  not  only  for  the  infant's  other  eye, 
but  for  those  who  are  taking  care  of  it.  Therefore  one  must  avoid  all 
spattering,  and  should  cover  the  infant's  well  eye  before  beginning  the 
irrigation. 

In  the  irrigation  of  the  eye  one  should  first  turn  the  child's  head  a 
little  to  the  diseased  side,  and  with  the  fingers  of  the  left  hand  gently 
separate  the  lids  as  far  as  possible.  Then,  holding  the  dropper  with  the 
right  hand,  irrigate  between  the  lids,  directing  the  stream  from  the  nose. 
After  each  irrigation  vaseline  should  be  applied  to  the  edge  of  the  lids. 
This  should  be  done  at  least  every  half-hour,  day  and  night,  until  the 
swelling  has  so  far  subsided  as  to  preclude  the  danger  of  any  secretion 
being  retained.  For  irrigation  many  solutions  have  been  advocated. 
The  most  simple,  and  perhaps  the  best,  is  a  saturated  solution  of  boracic 
acid,  or  one  of  bichloride  of  mercury  in  the  strength  of  0.05  gramme 
(1  grain)  to  480  c.c.  (1  pint)  of  distilled  water.  In  the  later  stages  of  the 
disease,  in  which  all  the  tissues  are  relaxed,  a  solution  of  nitrate  of  silver, 
or  still  better  of  protargol  or  argyrol,  two  per  cent,  in  strength,  painted  on 
the  conjunctiva  with  a  camel' s-hair  brush  once  daily,  early  in  the  disease, 
is  very  effective  in  shortening  the  course  of  the  disease. 

DISEASES    OP    THE    NEOK. 

Hsematoma  of  the  Sterno-cleido-mastoid  Muscle. — During  the  birth 
of  the  child,  either  from  the  violence  of  the  expulsive  efforts  of  the 
uterus,  or,  as  more  frequently  happens,  from  the  pressure  of  the  forceps 
in  head  presentations,  or  from  too  vigorous  traction  upon  the  feet  in 
breech  presentations,  or  for  no  assignable  reasons,  the  sterno-mastoid 
muscle  may  be  partially  ruptured  in  its  sheath  and  a  hsematoma  form  be- 
tween the  torn  ends.  This  tumor  may  be  either  in  the  sternal  or  in  the 
clavicular  portion  of  the  muscle,  or  may  be  just  above  the  junction  of  the 
two.  For  a  short  time  it  is  soft  and  tender,  but  gradually  it  loses  its 
sensitiveness  and  becomes  converted  into  fibrous  tissue,  which  then  tends 
to  contract.  It  may  appear  as  a  small  tumor,  but  in  infants  with  fat 
necks  it  may  not  be  noticeable  at  first.     As  turning  the  head  towards  the 


282  PEDIATRICS. 

affected  side  lessens  the  tension  npon  the  swelling,  the  infant  will  rigidly 
hold  its  head  in  that  position.  It  is  in  this  Avay  that  cases  of  infantile 
torticollis  are  thought  by  most  writers  to  arise. 

Treatment. — After  the  painful  stage  has  passed,  the  treatment  is  by 
gentle  massage  and  manipulations  addressed  to  stretching  the  shortened 
muscle.  If  these  methods  fail,  the  child  must  be  placed  in  the  hands  of 
an  orthopaedic  surgeon  for  more  extended  treatment,  either  by  appa- 
ratus or  by  division  of  the  tendinous  attachments  of  the  sterno-mastoid 
muscle. 

Branchial  Fistulae. — At  an  early  period  of  development  the  neck  of 
the  foetus  has  along  its  sides  a  series  of  four  branchial  clefts,  which  com- 
municate freely  with  the  oesophagus  and  represent  the  gills  of  aquatic 
animals.  The  upper  one  of  these  forms  the  tympanum  and  the  eustachian 
tube,  the  rest  are  normally  obliterated.  Sometimes  we  find  traces  of 
these  branchial  clefts  in  the  form  of  small  fistulous  tracts  which  admit  a 
probe  a  short  distance  and  end  blindly.  Their  most  frequent  seat  is 
just  above  the  sterno-clavicular  articulation,  but  they  may  be  found  any- 
where along  the  anterior  border  of  the  sterno-mastoid  muscle.  Some- 
times the  entrance  of  these  fistulae  becomes  stopped,  so  that  they  dilate 
and  form  large  cysts  containing  mucus,  blood,  and  atheromatous  detritus. 
Tliese  form  at  times  large  and  unsightly  bunches,  Avhich  require  surgical 
treatment.  Often  the  operation  of  obliterating  them  is  not  an  easy  one, 
for  they  are  apt  to  have  deep  and  complicated  attachments. 

Treatment. — If  they  do  not  cause  any  inconvenience  it  is  better  to  let 
them  alone,  as  they  often  prove  very  intractable  to  treatment.  If  they 
are  annoying  because  of  a  slight  mucous  discharge,  we  can  try  to  eradi- 
cate them  with  the  galvano-cauter}%  or  by  passing  a  probe  into  the  wound 
and  dissecting  from  around  it  the  lining  of  the  sinus. 

DISEASES  OF  THE  TRUNK. 

Mastitis. — In  certain  infants  during  the  early  days  of  life  we  find  a 
swelling  and  hardness  of  one  of  the  mammae.  This  condition  appears 
to  be  an  inflammatory  one,  and  is  abnormal.  In  connection  with  the 
swohen  condition  of  the  mamma,  a  secretion  is  found  to  come  from  the 
nipple  which  corresponds  closely  to  milk,  and  which  has  been  called 
"witches'  milk." 

A  number  of  analyses  have  been  made  of  this  fluid,  and  the  follow- 
ing are  some  of  them  : 

(Schlossborger.) 

Fat 0.82 

Casein,  sugar,  and  extractives 2.83 

Mineral  matter 0.05 

Total  solids 3.70 

Water 96.30 

100.00 


DISEASES    OF    THE    NEW-BORN. 

(Von  Gesner.) 

Fat , 1.45 

Casein 0.55 

Other  proteids 0.49 

Sugar , 0.95 

Mineral  matter 0^ 

Total  solids 4.26 

Water 95.74 


283 


100.00 

This  condition  occurs  in  boys  as  well  as  in  girls,  and,  as  far  as  we 
know,  has  no  special  significance.  With  ordinary  antiseptic  precautions, 
the  inflammation  usually  subsides  in  a  few  days,  leaving  the  affected 
breast  the  same  size  as  the  other.  Manipulation  to  express  the  milk 
should  be  strictly  avoided.  The  following  case  represents  this  condition 
of  the  mamma  in  a  female  one  week  old : 

The  swelling  of  the  mamma  was  noticed  on  the  foui'th  day  of  her  life.  A  little 
fluid  looking  like  diluted  milk  could  be  expressed  from  the  mamma.  The  treatment 
of  the  case  was  simply  to  keep  it  thoroughly  clean  by  washing  it  with  sterilized  water, 
carefully  drying  it,  and  applying  a  compress  with  a  little  simple  ointment  on  it. 


Depressed  Sternum. — There  are  a  great  many  congenital  malforma- 
tions which  may  occur  in  different  parts  of  the  thorax.     Fig.  73  repre- 

FiG.  73. 


Congenital  depressinu  of  gteniuin.     Male,  C,  yoars  old. 

sents  one  of  these.     It  occurred  in  a  boy  who  was  born  with  a  depression 
of  the  lower  part  of  the  sternum. 

He  was  six  years  old  when  first  seen,  and  had  a  rounded  depression,  about  4 
cm.  (IJ  inches)  in  diameter,  beginning  at  the  third  costal  cartilage  and  extending 
to  the  ensiform  cartilage.  He  was  perfectly  healthy.  The  cardiac  dulness  extended 
to  2.6  cm.  (1  inch)  to  the  left  of  the  mammary  line,  and  its  impulse  was  in  the 
fourth  left  interspace.  The  spinal  column  was  straight.  The  epiphyses  of  the  wrists 
were  slightly  enlarged,  but  there  was  no  other  evidence  of  rhachitis.     When  he  was 


284  PEDIATRICS. 

two  mouths  old  he  had  a  severe  attack  of  pertussis,  whicli  histed  for  over  two  mouths. 
At  five  years  of  age  he  had  a  very  severe  attack  of  bronchitis. 

Although  this  depression  of  the  sternum  was  present  at  birth,  and  later  increased 
in  depth  and  in  circumference,  it  eventually  ceased  to  enlarge.  The  circumference 
of  his  head  and  that  of  his  chest  was  50.5  cm.  (20  inches).  The  heart  was  somewhat 
displaced  upward  and  to  the  left,  but  was  apparently  unaffected  by  its  abnormal 
position.  Lisrht  gymnastic  exercises  to  broaden  the  chest  and  to  strengthen  the 
thoracic  muscles  were  advised  for  treatment.  Such  a  malformation  as  this  sometimes 
results  as  one  of  the  changes  subsequent  to  Potfs  disease.  More  often  the  sternum 
protrudes,  but  occasionally  recession  takes  place,  closely  resembling  the  condition  in 
this  case. 

Prominent  Sternum. — A  prominence  of  the  sternum,  called  pigeon- 
breast,  occurs  more  often  than  the  depression.  It  may  happen  without  an 
assignable  cause,  or  it  may  be  due  to  rhachitis.  and  may  also  result  from 
some  .spinal  distortion,  such  as  that  of  Pott's  disease,  or  lateral  curvature. 
In  the  latter  case  the  sternum  is  often  tilted  to  one  side. 

Spina  Bifida. — Spina  bifida  consists  of  a  lack  of  closure  of  the 
lammas  of  the  vertebra?.  This  condition  is  normal  at  a  certain  period  of 
intra-uterine  life,  but  when  persisting  to  a  later  period,  and  when  oc- 
curring at  l^irth,  becomes  abnormal  from  a  developmental  point  of  view 
and  represents  a  distinct  malformation.  As  the  fusion  of  the  lamina?  at 
the  base  of  the  spinous  process  takes  place  in  sequence  from  above 
downward,  the  most  frequent  seat  for  spina  bifida  is  in  the  lumbar  and 
lambo-sacral  regions.  There  it  appears  as  a  tumor  situated  exactly  in  the 
middle  line,  covered  sometimes  with  healthy  skin,  but  as  fi'equently  roofed 
over  by  nothing  but  a  thin  adherent  transparent  membrane.  Rarely  the 
tumor  is  solid,  containing  nothing  but  an  empty  sac  that  has  been  walled 
off  from  its  connections  with  the  spinal  canal.  It  is  then  called  spina 
bifida  occulta.  In  true  spina  bifida  the  tumor  is  filled  with  cerebro-spinal 
fluid,  which  can  be  seen  to  increase  in  amount  as  the  child  cries,  and  can, 
by  pressure  upon  the  sac,  be  forced  back,  in  this  case  often  giving  rise  to 
cerebral  symptoms.  According  to  the  contents  of  the  tumor,  spina  bifida 
~^has  been  divided  into  several  varieties. 

(a)  Spinal  Meningocele. — When  there  is  a  j^rotrusion  of  the  mem- 
branes filled  \Y\i\\  fluid  the  tumor  is  called  a  spinal  meningocele. 

(6)  Jleningo-myelocele. — The  most  common  form  is  where  the  spinal 
cord,  as  well  as  the  membranes,  is  found  in  the  tumor.  It  then  becomes 
a  menmgo-myelocele.  The  position  of  the  cord  in  these  tumors  is  a  very 
variable  one.  It  may  run  directly  through  the  tumor  and  even  be  sus- 
pended by  a  kmd  of  mesentery ;  or,  as  is  usually  the  case,  it  may  be 
spread  out  like  a  tan  over  the  surface ;  in  any  instance  it  is  rudimentary 
in  character. 

(c)  Syringo-myelocele. — Syringo-myelocele  is  a  rare  form,  in  which  the 
sac  is  formed  of  meninges  and  cord,  the  central  canal  of  the  cord  being 
dilated  to  make  the  cavity  of  the  tumor. 

Spina  bifida  occurs  usually  in  poorly  developed  infants,  and  in  a  lai^e 


DISEASES    OF   THE    NEW-BORN. 


285 


majority  of  cases  it  is  associated  with  other  mahbriuations,  sucli  as  con- 
genital hydrocephalus,  harelip,  club-foot,  paralysis  of  the  lower  ex- 
tremities, and  in  severe  cases  there  may  be  incontinence  of  urine  and  of 
faeces.  Sometimes  the  infant  is  well  formed  and  healthy  in  every  other 
respect. 

If  left  to  itself,  the  course  of  spina  bifida  is  in  one  of  two  directions : 
(1)  spontaneous  closure  and  obliteration  of  the  sac ;  (2)  ulceration  of  the 
sac,  usually  followed  by  convulsions  and  death.  In  the  first  case,  which 
is  very  rare,  the  sac  shrivels  up  and  thus  effects  a  spontaneous  cure.  The 
following  case  was  one  of  spontaneous  closure : 

Tig.  74. 


Spina  bifida.     Spontaneous  cure.     Male,  4V2  years  old.. 


A  boy,  four  and  one-half  years  old,  showed  an  elevated  cicatrix  in  the  lumbar 
region,  which  suggested  the  former  existence  of  a  spina  bifida.  The  case  was  seen 
by  Dr.  Lovett  when  it  was  eighteen  months  old,  and  so  far  as  could  be  learned  there 
had  been  a  large  tumor  present  at  birth.  The  sac  burst  in  this  case,  and,  contrary 
to  the  general  result,  the  child  did  not  die,  but  was  left  with  paralysis  of  the  legs, 
which  made  it  stand  in  the   curious  and   abnormal  position  shown  in  Fig.  74.      He 


286 


PEDlATHtCS. 


also  saffKi-ed  from  iiicont.iiieuco  of  urine  and  of  fieces.  The  child  had  never  walked, 
and  it  seemed  projjable  that  his  disability  was  caused  by  the  fact  that  the  nerves 
were  spread  on  the  walls  of  the  sac,  as  is  usual  in  many  cases,  and  that  they  Avere 
incorporated  in  the  cicatrix. 

A  result  such  as  is  described  in  the  above  case  is,  however,  very  ex- 
ceptional. The  rule  is,  either  that  there  is  an  ulceration  of  the  sac,  fol- 
lowed by  a  large  loss  of  cerebro-spinal  fluid,  convulsions,  and  death,  or 
that  the  opening  in  the  spine  being  very  small  the  loss  of  fluid  is  constant, 
and  the  result  is  the  same.  In  some  instances  there  is  an  infection  of 
pyogenic  organisms  through  the  walls  of  the  sac,  which  causes  a  septic 
meningitis  in  the  cord,  and  finally  in  the  brain.  Such  a  case  has  been 
reported  and  beautifully  illustrated  by  Holt,  showing  the  presence  of  the 
bacteria  and  a  resulting  purulent  hydrocephalus. 

Fig.  75  represents  another  case  of  spina  bifida  which  will  illustrate 
the  ordinary  course  of  the  affection. 


Pig.  75. 


^ 

[  ■■^:^11 

■M  ,         .-,„,„                  ''                               ^^IPEj^MBm 

1 

Spina  bilida  of  dorsal  lumbar  region.     Infant  4S  hours  old.     Died  when  lu  days  old. 

It  shows  a  large  spina  bifida  in  the  dorso-lumbar  region.  Tlie  membrane  cover- 
ing the  tumor  was  so  translucent  that  the  spinal  cord  could  be  plainly  seen  through  it. 
At  birth  there  was  a  small  tumor.  It  filled  with  fluid  at  the  end  of  twelve  hours,  and 
at  the  end  of  forty-eight  hours  it  looked  as  it  does  in  this  picture.  The  top  of  the 
tumor  suppurated,  the  fluid  began  to  leak  away,  and  the  child  died  within  ten  days. 

This  is  the  course  pursued  by  the  disease  in  the  majority  of  cases 
which  are  not  operated  upon. 


Fig.  76  represents  the  case  of  a  boy  five  years  old,  who  had  had  this  large  tumor 
since  birth.  It  was  situated  over  the  lumbar  region  of  the  spinal  cord,  and  in  the 
median  line.  The  fluid  was  withdrawn  several  times  for  purposes  of  examination, 
and  when  the  sac  was  lax  an  opening  5  cm.  (2  inches)  long  could  be  felt  in  the  spinal 
canal.  It  was  elliptical  iir  shape.  From  the  fact  that  the  child  suffered  from  incon- 
tinence of  urine  and  had  a  certain  degree  of  paralysis  of  the  legs,  it  was  fair  to  infer 
that  the  nerve-supply  of  tlie  legs  and  pelvis  was  incorporated  in  the  tumor. 

This  case  was  tapi)e(l   and  treated   with  an  injection  of  Morton's  fluid,  but  the 


DISEASES    OF    THE   NEW-BORN.  287 

treatment  was  entirely  unsuccessful,  and  although  the  sac  was  aspirated  several  times 
the  fluid  always  returned. 

Treatment. — The  only  rational  treatment  of  spina  bifida  is  by  opera- 
tion, and  the  operation  now  commonly  done  is  excision  of  the  sac  and 
closure  of  its  neck.  The  subsequent  development  of  internal  hydrocepha- 
lus is  unfortunately  not  uncommon. 

Fig.  76. 


Spina  bifidci  (if  luiul);ir  region.     Male,  5  years  old. 

Rhachischisis. — Rhachischisis  is  one  of  the  principal  forms  of  con- 
genital defects  of  the  spine.  It  is  characterized  by  a  deficiency  of  the 
vertebral  arches  either  complete  or  partial.  The  cord  is  rudimentary  and 
is  split  open  so  that  the  endothelial  lining  of  the  central  canal  is  exposed. 
This  may  occur  in  the  whole  of  the  cord  or  in  a  part  of  it,  constituting  total 
or  partial  rhachischisis.  This  disease  is  of  pathological  rather  than  clini- 
cal interest,  as  the  infants  die  in  a  short  time. 

Phlebitis  and  Arteritis  Umbilicalis. — The  cause  of  both  of  these  con- 
ditions is  a  septic  infection  of  the  umbilical  stump.  It  is  considered  by 
most  pathologists  to  begin  as  an  inflammation  of  the  perivascular  cellular 
tissue,  and  only  secondarily  to  invade  the  walls  of  the  vessels.  The  region 
around  the  umbilicus  is  red  and  hot,  and  we  may  be  able  by  gentle  press- 
ure to  squeeze  a  few  drops  of  pus  from  the  stump  of  the  cord.  It  is  a 
very  dangerous  affection,  as  septic  emboli  readily  pass  from  the  infected 
vessels  into  the  generaf  circulation  and  set  up  metastatic  inflammation  in 
the  thoracic  as  well  as  in  the  abdominal  organs. 

Treatment. — The  treatment  is  to  sustain  the  infant's  vitality  by  stimu- 
lation and  thoroughly  to  disinfect  the  umbilicus  with  solutions  of  bichloride 
of  mercury  or  carbolic  acid,  fblloAved  by  the  application  uf  boracic  acid 
or  iodoform  powder.     A  flaxseed  poultice  is  often  of  service,  and  some 


288  PEDIATRICS. 

authors  rccominend  placing  the  mfant  upon  its  abdouiL-u  iu  order  thai: 
gravity  may  aid  in  draining  away  the  pus. 

Congenital  Umbilical  Hernia  into  the  Cord. — Dr.  Howard  ]\larsh.  in 
the  Report  of  St.  Bartholomew's  Hospital  tor  1874,  calls  attention  to  the 
''  familiar  anatomical  fact  that  from  about  the  sixth  to  tlie  twelfth  week 
of  intra-uterine  life  the  caecum  and  neiglihoring  portions  of  the  ileum  are 
contained  in  the  part  of  the  umbilical  cord  which  is  next  to  the  body  of 
the  embryo,  and  that  they  sliould  subsequently  withdraw  into  the  cavity 
of  the  abdomen.  In  some  cases,  however,  this  recession  fails  to  take 
place,  and  the  intestine  remains,  even  up  to  the  tune  of  birth,  still  lodged 
in  the  beginning  of  the  cord,  which  is  dilated  in  the  form  of  a  membra- 
nous sac.""  Not  only  may  portions  of  the  intestine  be  thus  left  outside  of 
the  abdominal  wall,  but,  as  in  a  case  recently  operated  upon  by  Warren, 
the  liver  may  be  found  lying  m  a  hernial  sac  made  from  the  dilated  base 
of  the  umbilical  cord. 

The  infant  was  sent  to  Dr.  Warren  at  the  Massachusetts  General  Hospital  a  few 
hours  after  its  birth.  At  the  umbilicus  was  seen  the  cord,  which  was  greatly  distended 
at  its  point  of  insertion  into  the  abdomen,  forming  a  tumor  6.5  cm.  (2|  inches)  in 
diameter.  The  coverings  of  the  cord  were  inserted  into  a  raised  rim  of  skin,  and  were 
opaque,  so  that  the  contents  of  the  hernia  could  not  be  determined. 

When  the  infant  was  one  day  old,  Dr.  Warren  enlarged  the  umbilical  ring  some- 
what, separated  the  liver  from  the  myxomatous  tissue  of  the  cord,  which  was  in  some 
places  firmly  adherent  to  it,  and  returned  the  mass  within  the  abdomen.  The  wound 
was  tightly  closed  with  strong  silk  sutures.  There  was  considerable  shock  following 
the  operation,  but  there  were  no  symptoms  of  peritonitis.  In  two  weeks  the  wound 
had  healed,  and  the  infant  recovered. 

Fung-US  of  the  Umbilicus. — The  umbilical  cord,  after  being  ligatured 
at  birth,  falls  off  by  the  seventh  or  eighth  day,  leavmg  a  clean,  dn^  cica- 
trix. After  the  separation  of  the  cord  we  sometimes  find  a  red  protru- 
sion, with  a  moist  surface,  that  may  even  have  a  short  central  canal.  This 
is  generally  due  to  an  imperfect  disintegration  of  the  cord.  It  may  bleed 
very  readily  if  touched,  and  give  rise  to  a  dischai^e  so  irritating  that  the 
skm  for  some  distance  around  the  umbilicus  becomes  eczematous.  This 
condition  is  called/u?i^Ms  ov  polypus  of  the  umbilicus. 

Treatment. — The  treatment  is  very  simple.  The  larger  ones  are  best 
removed  by  ligation  ;  the  smaller  ones  can  be  destroyed  by  the  a^^plica- 
tion  of  nitrate  of  silver  or  the  actual  cautery. 

Meckel's  Diverticulum. — A  condition  Avhich  may  at  first  smiulate 
mubilical  polypus,  and  of  which  umbilical  polypus  may  be  a  symptom,  is 
the  persistence  of  a  Meckel's  diverticulum.  This  consists  of  the  persist- 
ence of  a  piece  of  intestme,  usually  patent,  connecting  the  small  intestine 
with  the  umbilicus.  It  represents  a  vitellme  duct  that  failed  to  atrophy 
Avhen  the  jDlacental  circulation  became  established,  and  betrays  its  presence 
by  an  escape  of  faeces  from  the  miibilicus.     It  is  a  rare  malformation. 

Umbilical  Hernia, — The  ordinary  umbilical  hernia,  which  is  simply  a 


DISEASES   OF   THE   NEW-BORN.  289 

protrusion  of  a  knuckle  of  the  intestines  through  the  unclosed  abdominal 
opening  left  by  the  separation  of  the  cord,  is  of  very  common  occurrence. 

Treatment. — The  lighter  grades  tend  to  recover  spontaneously,  and  it  is 
not  advisable  to  operate  upon  them,  or  in  fact  on  any  umbilical  hernia, 
until  it  has  proved  to  be  absolutely  intractable,  for  it  is  an  operation 
accompanied  by  considerable  danger  to  the  life  of  the  infant.  The  lighter 
grades  of  umbilical  hernia  are  usually  easily  reduced,  but  there  is  often 
great  trouble  in  keeping  them  so.  Various  devices  are  employed  for  this 
purpose,  but  most  of  them  are  very  unsatisfactory.  At  the  Children's 
Hospital  we  are  in  the  habit  of  proceeding  in  the  following  manner : 

Having  gently  reduced  the  hernia,  the  skin  of  the  abdomen  is  so 
pushed  up  between  the  fingers  that  it  makes  a  vertical  fold,  at  the  bottom 
of  which  lies  the  umbilicus.  The  hole  should  be  deep  enough  to  lay 
one's  finger  in  it.  The  tension  is  kept  up  by  applying  a  wide  strip  of  ad- 
hesive plaster  transversely  across  the  abdomen.  This  makes  a  pad  of 
flesh,  which  closes  the  umbilical  opening  and  retains  the  intestine  in  place. 
The*bure  is  a  slow  one,  and  the  treatment  must  be  continued  for  many 
months  in  severe  cases,  without  once  allowing  the  hernia  to  come  out. 
The  milder  cases  are  also  aided  by  exercises  which  tend  to  develop  the 
abdominal  muscles.  This  can  be  very  simply  effected  by  having  the  child 
lie  on  the  floor,  and,  while  the  feet  are  held  down,  making  him  rise  to  a 
sitting  position  with  the  back  held  straight.  This  is  accomplished  by  the 
rectus  muscles  of  the  abdomen,  and  if  the  opening  is  a  transverse  one  it 
tends  to  close  it. 

Fig.  77  represents  an  extreme  case  of  umbilical  hernia  in  an  infant  five  months 
old.     The  hernia  caused  an  eversion  of  the  whole  umbilical  region. 

¥m,  77. 


Large  umbilical  hernia.     Infant  5  months  old. 

Cases  of  incarcerated  and  even  strangulated  umbilical  hernia  have  been 
reported,  but  are  very  rare.  A  few  have  been  operated  upon  successfully. 
The  danger  from  all  such  procedures  is  usually  considered  great,  but  there 
has  been  such  an  advance  made  in  the  modern  methods  of  abdominal 

19 


290  PEDIATRICS. 

surgery  that  the  operation  is  looked  upon  with  increasing  favor.  Cases 
of  hernia,  whether  umbihcal  or  inguinal,  are  especially  difficult  to  manage 
if  the  infant  has  pertussis  or  some  similar  disease. 

Inguinal  Hernia. — The  most  common  forms  of  inguinal  hernia  that 
occur  in  young  children  are  (1)  the  congenital,  (2)  the  funiculi',  and  (3) 
the  infantile  or  encysted.  An  ordinary  acquired  form  such  as  is  the  rule  in 
the  adult  may  be  met  with,  but  it  is  not  so  common.  Strangulated  and 
incarcerated  hernise  occur  at  times,  as  in  the  adult,  although  they  are 
rare. 

There  seems  to  be  some  evidence  that  the  tendency  to  hernia  is 
hereditary.  Felizet  reports  eighty-five  cases  of  hernia  occurring  in  his 
practice,  in  which,  omitting  all  cases  in  which  the  father  pursued  some 
laborious  trade,  such  as  that  of  a  blacksmith,  he  found  that  in  24.7  per 
cent,  the  parents  had  had  similar  hernias.  Malgaigne  reports  a  percent- 
age of  29  due  to  heredity  in  a  series  of  three  hundred  and  sixteen  cases 
of  hernia. 

Infants  are  at  times  brought  to  our  hospitals  with  a  history  of  colic 
who,  on  examination,  are  found  to  have  more  or  less  incarceration  of 
these  hernife ;  which  emphasizes  the  importance  of  making  a  systematic 
physical  examination  in  every  case  for  abdominal  hernia,  and  of  not 
taking  it  for  granted  that  the  symptoms  are  caused  by  indigestion. 

(1)  Congenital  Form. — The  congenital  form  is  that  variety  in  which 
the  knot  of  intestine  has  made  its  way  along  a  still  patent  funicular  pro- 
cess. If  it  reaches  into  the  scrotum  it  will  be  found  completely  to  en- 
velop the  testicle. 

(2)  Funicular  Form. — In  the  funicular  form,  the  tunica  vaginalis 
having  become  shut  off  from  the  funicular  process  just  above  the  testicle, 
the  hernia  comes  down  the  patent  process,  but  does  not  envelop  the 
testicle  as  in  the  preceding  variety. 

(3)  Infantile  Form. — Compared  with  the  two  forms  just  mentioned, 
the  infantile  or  encysted  form  of  hernia  is  quite  rare,  nor  can  it  be  diag- 

-nosticated  with  certainty  without  an  operation.  In  it  the  funicular  pro- 
cess has  closed  above  but  not  below,  and  the  intestine  encased  in  a  pouch 
of  peritoneum  forces  its  way  into  the  process  and  descends. 

Diagnosis. — The  diagnosis  between  direct  and  indirect  hernia  has  little 
importance  in  childhood,  as  the  inguinal  canal  is  so  short  that  the  rings 
are  practically  at  the  same  level.  The  condition  which  Avill  be  most 
readily  confounded  with  hernia  is  hydrocele.  Both  give  rise  to  an  elastic 
tumor  in  the  inguinal  region  and  in  the  scrotum,  and  in  fact  resemble 
each  other  in  many  ways.  Hydrocele  is  translucent  by  transmitted  light ; 
hernia  is  opaque.  Hydrocele  is  always  dull  on  percussion ;  hernia  is 
usually  resonant.  If  you  can  reduce  them,  hydrocele  will  go  back  slowly 
and  noiselessly,  hernia  at  the  last  quickly  and  with  a  gurgling  sound. 
Hydrocele  gives  no  impulse  on  coughing ;  hernia  usually  does.  Lastly, 
in  feeling  for  the  inguinal  ring  in  hernia  it  is  found  to  be  filled  with  the 


DISEASES   OF   THE   NEW-BORN.  291 

neck  of  the  tumor ;  in  hydrocele  it  is  either  empty  or  filled  by  a  narrow- 
stalk. 

Treatment, — Most  of  the  hemise  that  will  be  met  with  in  children  are 
easily  reducible,  but  we  should  remember  that  in  attempting  to  get  them 
back  into  the  abdominal  cavity  we  must  use  the  greatest  care,  as  nowhere 
can  a  little  rough  manipulation  do  more  harm.  If  the  hernia  cannot  be 
easily  replaced,  we  should  not  think  of  leaving  it  w^here  it  is,  smiply  be- 
cause it  gives  rise  to  no  alarming  symptoms  on  the  part  of  the  child. 
No  infant  is  safe  with  an  irreducible  hernia,  and  the  sooner  such  a  case 
is  placed  in  the  hands  of  a  surgeon  the  better.  Although  the  treatment 
of  inguinal  hernia,  whether  by  actual  operation  or  by  the  application  of 
the  usual  trusses,  should  be  in  surgical  hands,  yet  one  method  of  treatmg 
these  hemise  is  so  simple  and  safe  that  every  medical  man  should  know 
about  it ;  in  fact,  in  our  children's  clinics  in  Boston  it  is  much  used  for 
all  children  under  a  year  and  a  half.  This  method  is  the  application  of  a 
worsted  truss  made  of  a  skein  of  yarn  which  is  passed  under  the  back. 
The  separated  loop  is  around  the  side  where  the  hernia  is,  and  the  un- 
separated  end  of  the  skein  is  brought  forward  and  passed  through  the  loop 
in  the  groin  and  up  on  to  the  back  where  it  is  fastened.  In  this  w'ay  a 
soft  slip-knot  is  made  W' hich  lies  directly  over  the  inguinal  ring  and  makes 
an  excellent  truss. 

Femoral  Hernia. — In  femoral  hernia  the  gut  escapes  from  the  pelvis 
under  Poupart's  ligament,  and,  making  its  way  through  the  femoral 
canal,  shows  itself  as  a  tumor  directly  under  the  saphenous  opening.  It 
can  be  diagnosticated  at  once  from  inguinal  hernia  by  putting  the  fmger 
on  the  spine  of  the  pubes  and  noticing  whether  the  origin  of  the  tumor 
is  to  the  outer  or  the  inner  side  of  that  point.  If  outside,  one  is  sure  the 
hernia  came  through  the  femoral  canal,  no  matter  how  far  it  may  have 
extended  up  on  to  the  abdomen.  Femoral  hernia  is,  how' ever,  extremely 
rare  in  young  children,  even  in  girls.  In  infancy  the  spine  of  the  pubes, 
Poupart's  ligament,  and  the  anterior  superior  spine  of  the  ilium  are  all 
much  nearer  together  than  in  the  adult.  As  a  consequence,  the  femoral 
opening  is  so  small  and  so  well  protected  that  it  is  usually  impossible  for 
the  hernia  to  force  its  way  through. 

Hydrocele. — Several  anatomical  varieties  are  met  wdth  in  hydrocele, 
as  in  hernia.  Thus,  if  the  collection  of  fluid  occupies  a  freely  open 
funicular  process,  w-e  have  the  congenital  variety,  and  the  fluid  can  easily 
be  returned  to  the  abdommal  cavity  by  placing  the  child  on  its  back  and 
elevating  the  scrotum.  This  is  true  also  of  funieular  hydrocele,  in  which 
the  fluid  occupies  an  open  funicular  process,  but  is  bounded  below^  at  the 
point  where  the  tunica  vaginalis  has  become  w-alled  off,  leaving  the  testi- 
cle in  a  separate  compartment  underneath.  When  the  funicular  process 
has  become  walled  off  from  the  abdomen,  but  is  still  in  communication 
wdth  the  tunica  vaginalis,  there  may  be  a  collection  of  fluid,  wdiich  is  then 
known  as   an  infantile  hydrocele;  in  this  form  the  fluid  is  irreducible. 


292  PEDIATRICS. 

True  hydrocele  of  the  tunica  vaginaUs  may  be  met  with  in  children  as  well 
as  in  adults,  but  it  is  rare. 

Encysted  Hydrocele  of  the  Cord. — There  is  another  form  of  hydrocele 
which  often  escapes  recognition,  but  perhaps  still  oftener  is  diagnosticated 
as  hernia  and  treated  with  a  truss.  This  is  the  encysted  hydrocele  of  the 
cord.  If  in  the  course  of  the  spermatic  cord  a  hard,  rounded  swelling 
appears,  and  the  testicle  is  found  in  its  proper  position  in  the  scrotum  and 
the  inguinal  ring  clear,  one  is  very  surely  dealing  with  a  hydrocele  of  this 
kmd.  Having  made  the  diagnosis,  it  should  be  evacuated  with  a  fine 
aspirating  needle.  About  4  c.c.  (1  drachm)  of  clear  straw-colored  fluid 
is  generally  drawn  off,  and  the  tumor  usually  disappears. 

Encysted  Hydrocele  of  the  Canal  of  Nuck. — Analogous  to  hydrocele  of 
the  cord  in  boys  is  an  accumulation  of  fluid  in  the  canal  of  Nuclc  in 
girls.  The  appearance  of  the  swelling  is  the  same  in  both  cases,  and  the 
treatment  should  be  the  same. 

Treatment. — The  treatment  of  all  forms  of  irreducible  hydrocele  is 
first  by  aseptic  evacuation  of  the  fluid  with  a  fine  canula  and  trocar,  or 
by  an  aspirating  needle.  If  this,  after  repeated  trials,  fails  to  effect  a 
cure,  extirpation  of  the  sac  is  the  only  sure  method,  although  the  injec- 
tion of  a  weak  solution,  of  iodine  is  highly  recommended  by  many  au- 
thors. It  is,  however,  dangerous  in  children,  as  the  occasional  connection 
of  the  hydrocele  sac  with  the  abdomen  is  not  to  be  forgotten.  Reducible 
forms  of  hydrocele  are  generally  to  be  treated  by  a  truss,  in  the  same 
manner  as  hernias,  to  try  to  effect  a  closure  of  the  neck  of  the  canal.  If 
this  is  successful  they  can  then  be  treated  in  the  ordinary  way.  The 
outlook,  however,  is  poor,  and  such  treatment  is  generally  unsatisfactory. 
Undescended  Testicle. — The  testicle  should  descend  into  the  scro- 
tum at  about  the  eighth  month  of  intra-uterine  life.  In  certain  cases  it 
does  not  descend,  and  if  the  descent  does  not  take  place  within  the  first 
few  years  of  life  its  function  is  lost  from  atrophy.  It  is,  therefore,  im- 
portant in  those  cases  in  which  the  testicle  descends  and  returns  to  the 
abdominal  cavity  to  retain  it  in  the  scrotum  by  means  of  apparatus. 
Operation  for  this  condition  is  not  often  successful.  At  times  an  unde- 
scended testicle  is  found  in  combination  with  an  inguinal  hernia.  The 
following  case  of  this  kind  came  under  my  care  about  two  years  ago  : 


A  boy,  four  years  old,  was  discovered  to  have  an  inguinal  hernia.  The  testicle 
was  also  found  at  times  to  be  absent  on  the  side  of  the  hernia.  Sometimes  the  her- 
nia would  descend  and  the  testicle  remain  in  the  abdominal  cavity,  and  again  the  testi- 
cle would  come  down  with  the  hernia.  It  was  exceedingly  difficult  to  maintain  the  ■ 
testicle  in  the  scrotum,  even  when  it  was  found  to  be  there,  as  it  would  slip  back  with 
the  greatest  facility.  Dr.  Lovett  finally  succeeded  in  seeing  the  boy  at  a  time  when 
both  the  testicle  and  the  hernia  were  down,  and  in  reducing  the  hernia  while  the  testi- 
cle was  kept  in  the  scrotum.  A  carefully  adapted  truss  was  then  applied  so  as  to  pre- 
vent the  testicle  from  returning  to  the  abdominal  cavity  and  the  hernia  from  entering 
the  scrotum. 


DISEASES   OF   THE   NEW-BORN.  ^  293 

Tumors  of  the  Testis. — We  may  at  birth  find  an  enlargement  of  the 
testis  clue  to  sarcoma,  teratoma,  congenital  syphilis,  or  carcinoma.  The 
former  is  much  the  more  common. 

Malformations  about  the  Rectum. — At  an  early  stage  of  develop- 
ment of  the  embryo  the  intestinal  canal  ends  blindly,  and  afterwards  by  an 
invagination  of  the  outside  wall  a  communication  is  brought  about  and  the 
stomodaeum  formed.  An  analogous  process  of  development  goes  on  at  the 
other  end  of  the  intestinal  tube,  and  results  in  the  formation  of  the  rectum 
and  anus.  The  hind-gut  at  first  ends  blindly,  then  as  it  descends  it  is  met 
by  an  ascending  dimple,  and  usually  these  two  fuse  and  the  protodceum  is 
formed. 

As  in  the  mouth  a  series  of  malformations  may  arise  from  a  failure  in 
the  completion  of  this  process,  so  in  the  anal  region  we  may  meet  with  a 
similar  series.  The  rectum  may  have  come  into  its  normal  relations  and 
the  anal  depression  have  failed  to  form,  or  it  may  have  gone  the  whole  of 
the  distance  between  the  end  of  the  intestine  and  the  skin  and  yet  the 
final  step,  the  fusion  of  the  membranes,  have  failed  to  take  place.  To  both 
of  these,  and  to  any  intermediate  condition,  the  name  of  Imperforate  rectum 
is  given.  On  the  other  hand,  with  the  rectum  and  the  anus  fused  we  may, 
nevertheless,  find  a  thin  parchment-like  membrane  spread  over  the  exter- 
nal orifice  just  where  the  skin  and  the  mucous  membrane  join.  This  is 
called  imperforate  anus. 

Treatment. — When  an  infant  is  born  the  physician  should  carefully 
examine  it,  in  order  to  determine  whether  it  has  any  malformation.  The 
most  important  malformations  which  it  is  necessary  to  recognize  are  those 
at  the  anus.  Unless  an  infant  has  a  passage  of  meconium  soon  after  its 
birth,  an  examination  should  be  made  in  the  rectum  with  the  finger,  and 
if  the  anal  opening  is  found  to  be  closed,  either  just  at  the  outlet  or  higher 
up,  we  must  consider  what  is  to  be  done  to  refieve  this  condition.  If 
nothing  but  a  web  obstructs  the  anus,  we  can  easily  break  it  through  with 
a  director  and  then  dilate  the  orifice  with  the  finger.  If  there  is  more 
than  the  thinnest  bulging  membrane,  a  cutting  operation  will  have  to  be 
done,  and  perhaps  a  severe  one,  so  that  the  case  should  at  once  be  placed 
in  the  hands  of  a  surgeon. 

Occlusion  of  the  Vag-ina. — Sometimes  we  find  a  thin  gray  velum  ex- 
tending across  the  mouth  of  the  vagina  from  just  below  the  urethral  open- 
ing to  the  posterior  commissure  and  blocking  up  the  vagina.  It  may  be 
complete  or  partial. 

Treatment. — This  condition  should  be  dealt  with  while  the  infant  is 
still  young,  as,  if  left  until  puberty,  it  will  cause  a  retention  of  the  menses, 
and,  moreover,  by  that  time  will  have  become  much  thicker  and  perhaps 
quite  vascular.  It  is  easily  broken  through  in  the  young  child,  and  if  a 
piece  of  carbolized  cotton  be  put  between  the  torn  edges  to  prevent  them 
from  adhering,  the  malformation  can  be  cured  permanently.  Atresia  from 
inflammation  of  the  labia  is  said  to  occur  in  rare  instances. 


294  PEDIATRICS. 

Hypospadias. — The  malformation  known  as  hypospadias  is  the  result 
of  an  arrest  of  development  in  the  formation  of  the  urethra  and  of  the 
corpus  spongiosum.  The  urethral  groove  should  normally  be  converted 
into  a  canal  by  the  growth  and  joining  together  of  its  sides.  This  process 
begins  at  the  base  and  extends  to  the  end  of  the  penis.  By  an  interrup- 
tion of  this  process  the  urethra  may  be  brought  to  an  end  and  open  at  any 
point  between  the  peno-scrotal  angle  and  the  base  of  the  glans.  In  the 
most  common  forms  of  hypospadias  the  glans  alone  is  imperforate. 

Treatment. — The  treatment  is  wholly  by  plastic  operation,  and  it  re- 
quires the  most  delicate  surgery  to  obtain  a  good  result  in  the  face  of  the 
many  serious  obstacles  that  this  malformation  presents. 

Epispadias. — The  malformation  of  epispadias,  in  which  the  urethral 
canal  opens  upon  the  dorsum  of  the  penis,  is  still  more  difficult  to  deal 
with  than  is  hypospadias.  It  is  commonly  associated  with  extroversion 
of  the  bladder,  and  is  very  rare. 

Treatment. — A  partial  plastic  operation  and  the  wearing  of  some  form 
of  urinal  constitute  about  all  that  can  be  done  for  these  cases. 

Cong-enital  Obliteration  of  the  Bile-Ducts. — One  of  the  rarer  forms 
of  congenital  malformations  in  new-bom  infants  is  represented  by  the  ob- 
literation of  the  bile-ducts.  The  most  extended  work  which  has  appeared 
in  the  literature  of  this  subject  is  that  of  Dr.  John  Thompson,  of  Edin- 
burgh. 

Pathological  Anatomy. — There  are  a  number  of  different  morbid  pro- 
cesses which  have  been  supposed  to  produce  this  pathological  lesion  of  the 
ducts.  Each  of  these  processes  has  in  certain  cases,  in  all  probability,  had 
much  to  do  with  causing  the  disease,  but  it  is  usually  the  combination  of  one 
or  more  of  them  which  must  be  considered  in  determining  its  etiology. 
Thus,  the  results  of  intra-uterine  peritonitis,  by  compressing  the  ducts,  or  by 
being  a  source  of  inflammation  which  has  spread  to  the  walls  of  the  ducts, 
may  finally  cause  their  obliteration.  A  primary  inflammation  or  lesion  of 
the  ducts  themselves  may  produce  this  result,  or  it  may  arise  from  an  actual 
^ — arrest  or  defect  of  development.  In  this  connection  congenital  syphilis 
should  be  referred  to  as  in  some  cases  producing  lesions  of  the  ducts,  but 
this  and  other  causes  do  not  necessarily  play  an  important  part  in  the  dis- 
ease. 

The  complete  discussion  of  the  causes  of  congenital  malformation  of 
the  bile-ducts  would  hardly  have  a  place  in  a  general  work  on  clinical 
medicine,  but  it  is  sufficient  to  say  that  in  the  great  majority  of  cases  the 
evidence  is  in  favor  of  defective  development  as  being  the  chief  cause. 
This  malformation  probably  affects  to  a  considerable  extent  the  walls  of 
the  ducts,  and,  as  Thompson  has  stated,  it  consists  in  the  narrowing  of 
their  lumen.  The  interference  which  is  thus  caused  to  the  outflow  of  bile 
gives  rise  to  a  catarrhal  condition  which  finally  blocks  and  obliterates  the 
ducts,  owing  to  the  inflammatory  process  spreading  to  the  walls  of  the 
ducts  and  the  gall-bladder.    This  progressive  inflammation  goes  on  slowly 


DISEASES   OF  THE   NEW-BORN.  295 

spreading,  the  local  condition  gradually  becoming  worse  during  many 
months  if  the  patients  live.  The  obliterated  ducts  or  gall-bladder,  or 
portions  of  them,  may  entirely  disappear,  not  even  leaving  a  distinct  band 
of  fibrous  tissue  to  indicate  their  original  position.  The  obliteration  gen- 
erally becomes  complete  at  a  variable  but  early  period  of  intra-uterine 
life ;  occasionally  it  does  not  occur  until  after  birth.  The  occurrence  of 
peritonitis  is  probably  in  most  cases  secondary  to  the  blocking  of  the 
ducts. 

When  the  lumen  of  the  duct  has  become  so  narrowed  that  the  bile 
does  not  pass  freely  into  the  intestine,  a  cirrhotic  condition  begins  in  the 
tissues  of  the  liver,  and  as  it  progresses  interferes  with  the  functions  of 
that  organ. 

At  the  post-mortem  examinations  of  these  cases  the  liver  usually  is 
found  to  be  much  enlarged  and  its  tissues  to  be  increased  in  consistency ; 
it  is  of  a  dark-brown  color,  owing  to  the  presence  of  numerous  masses 
of  inspissated  bile  in  the  smaller  bile-ducts.  In  a  large  number  of  cases 
there  is  found  a  complete  obliteration  of  some  part  or  parts  of  the  hepatic, 
common,  or  cystic  ducts,  or  of  the  gall-bladder,  while,  with  very  few  ex- 
ceptions, implication  of  the  blood-vessels  is  conspicuously  absent. 

In  speaking  of  the  explanation  which  may  be  given  for  the  occurrence 
of  the  symptoms  just  mentioned,  Thompson  remarks  that  the  reappear- 
ance of  the  disease  in  several  members  of  the  same  family  can  be  ex- 
plained only  by  the  theory  that  a  congenital  defect  of  development  is  in 
these  cases  the  cause  of  the  malformation.  The  fact  that  the  onset  of 
the  jaundice  is  not  contemporaneous  with  the  blocking  of  the  bile-ducts, 
and  usually  begins  several  days  after  birth,  he  explains  as  the  effect  on 
the  hepatic  cells  produced  by  the  great  changes  in  the  hepatic  circulation 
which  occur  in  new-born  infants.  The  presence  of  colored  meconium  in 
some  cases  and  of  only  white  discharges  in  others  is  due  to  the  blocking 
of  the  ducts  having  occurred  at  different  periods  of  intra-uterine  life. 

When  in  combination  with  the  colorless  ftecal  discharges  green 
material  is  passed  during  the  progress  of  the  disease,  this  occurrence  is 
probably  due  to  the  chemical  action  on  the  contents  of  the  intestine,  pro- 
duced in  various  ways,  one  of  which  may  arise  if  mercury  has  been 
administered.  The  tendency  to  spontaneous  hemorrhages  may  be  due  to 
the  occurrence  of  a  condition  of  chronic  blood-poisoning,  since  the  arrest 
of  the  outflow  of  bile  damages  the  liver  to  such  an  extent  that  its  func- 
tions are  interfered  with  and  organic  fluids  of  a  poisonous  nature  may 
thus  pass  into  the  circulation.  The  enlargement  of  the  spleen,  the  con- 
vulsions, and  the  vomiting  are  probably  more  or  less  connected  with  the 
same  condition  of  blood-poisoning.  The  fact  that  the  children  live  as 
long  as  they  do,  and  usually  do  not  become  emaciated  in  the  early  days 
of  life,  is  to  be  explained  on  the  ground  that  the  presence  of  bile  in  the 
intestine  is  not  absolutely  necessary  for  digestion.  When  the  nutrition 
and  general  health  begin  to  suffer,  it  is  probably  due  to  the  interference 


296  PEDIATRICS. 

which  the  secondary  changes  in  the  tissues  of  the  liver  are  causing  Avith 
the  more  important  functions  of  that  oi^an. 

Symptoms. — The  infants  who  are  bom  with  this  disease  are  either 
icteric  at  first  or  become  so  AAithin  the  first  few  weeks  of  Ufe.  They  often 
appear  otherwise  healthy  and  well  nourished.  In  some  cases  there  is  a 
discharge  of  normal  meconium  followed  by  colorless  dejections.  In  otiier 
cases  the  faecal  movements  are  clay-colored  from  the  very  first  and 
remam  so.  The  urine  is  deeply  stained  with  bile.  The  jamicUce  is  of  a 
dark-greenish  tinge,  lastmg  until  death,  which  occurs  from  mthin  a  few 
weeks  to  eight  months.  Spontaneous  hemorrhage  from  the  umbilical 
cord  commonly  occurs  within  the  first  two  weeks,  and  m  other  localities 
in  those  infants  who  survive  this  early  period.  The  liver  and  spleen  are 
increased  in  size.  If  the  infants  survive  for  some  months  they  become 
more  or  less  emaciated.  Convulsions  and  vomiting  are  apt  to  occur,  and 
death  usually  takes  place  from  exhaustion  or  from  some  trifling  inter- 
current disease. 

Treatment. — There  is  no  known  means  by  which  we  can  counteract 
the  results  of  this  malformation. 

Congenital  Obliteration  of  the  Intestine. — We  shall  merely  refer  to 
a  malformation  which  is  represented  by  an  obliteration  of  the  intestine. 
Malformations  of  this  kind  may  arise  from  constrictions  of  the  parts 
affected  by  fibrous  bands,  probably  the  remams  of  peritoneal  adhesions. 

Congenital  Malformations  of  the  CEsophagns  and  Stomach. — 
Congenital  malformations  of  the  oesophagus  and  stomach  are  rare,  and 
are  described,  in  connection  with  diseases  of  these  parts,  on  page  767. 

Malformations  of  the  Heart  and  the  Blood- Vessels. — The  various 
anomalies  of  the  heart  and  blood-vessels  are  described  on  page  720. 

DISRATES    OF    THE    EXTREMITIES. 

Fingers. — Various  malformations  of  the  extremities  are  met  with  in 
new-bom  infants,  one  of  these  is  six  instead  of  five  fingers. 

Another  malformation  of  this  kmd,  called  webbed  fingers,  is  quite 
common.     Surgical  interference  is  indicated  m  both  cases. 

Toes. — Infants  are  at  tunes  bom  with  extra  toes  and  u-ebbed  toes,  and 
it  becomes  a  surgical  question  to  determine  whether  they  shall  be  operated 
upon.  This,  of  course,  is  a  question  of  orthopEechcs,  and  is  one  which 
we  need  not  deal  \A-ith  except  so  far  as  to  appreciate  the  importance  of 
preparing  the  foot  properly  for  future  use.  The  greater  freedom  of  move- 
ment requfred  for  the  fingers,  and  the  fact  that  the  hand  is  always  m  sight, 
render  surgical  mterference  much  more  necessary  in  malformations  of  the 
hand  than  in  those  of  the  foot. 

Congenital  hypertrophy  of  the  feet  and  hands,  and  congenital  deficiency 
of  one  or  more  extremities,  may  be  spoken  of  in  this  connection,  but  are 
too  rare  to  be  more  than  referred  to.  These  malfomiations  have  been 
thoroughly  described  by  Thomas  Annandale. 


DISEASES   OF   THE    NEW-BORN.  297 

Club-Hand  and  Club-Poot. — Club-liancl  and  club-foot  are  congenital 
malformations  which  may  he  due  to  an  undeveloped  condition  of  either 
the  bones,  the  ligaments,  or  the  muscles.  In  the  more  simple  forms  the 
extremity  is  pulled  into  the  malposition  by  the  action  of  contracted  mus- 
cles and  tendons,  while  in  the  severe  forms  the  bony  framework  may  be 
so  misshapen  that  the  separate  segments  are  almost  unrecognizable. 
Club-hand  is  often  accompanied  by  absence  of  the  radius. 

TreatmExXt. — The  treatment  of  this  class  of  deformities  is,  of  course, 
purely  in  the  province  of  the  orthopaedic  surgeon.  All  that  we  wish  to  do 
in  referring  to  them  is  to  suggest  how  much  may  be  accomplished  by 
simple  manipulations  with  'the  hand.  The  mother  should  be  instructed 
to  rub  the  foot  and  leg  twice  daily,  and  to  make  firm  pressure  against  the 
shortened  muscles  by  trying  to  bring  the  hand  and  foot  into  the  normal 
position.  We  have  seen  slight  cases  cured  by  this  simple  means,  and  even 
moderately  severe  ones  so  much  benefited  that  subsequent  treatment  with 
orthopsedic  apparatus  became  much  easier. 

Congenital  Dislocation  of  the  Hip. — Congenital  dislocations  of  all 
the  joints  are  sometimes  found,  the  most  frequent  and  most  important 
being  dislocation  of  the  hip.  This  is  now  thought  to  be  caused  by  a 
faulty  development  of  the  acetabulum  and  the  head  of  the  femur. 

Symptoms. — The  symptoms  are  of  a  kind  that  readily  escape  notice 
during  infancy,  and  are  first  seen  when  the  child  should  begin  to  walk. 
It  is  then  noticed,  if  he  can  hold  himself  on  his  feet  at  all,  that  the  abdo- 
men is  very  prominent,  the  back  arched,  and  the  buttocks  seemingly  en- 
larged :  at  least  this  is  the  case  if  the  deformity  is  bilateral,  which  is  the 
form  usually  met  with.  On  examining  the  joint  we  find  that  the  trochan- 
ter is  above  Nelaton's  line,  but  it  can  by  traction  on  the  leg  be  drawn 
down  to  its  proper  place  without  causing  any  discomfort  to  the  child.  If 
the  deformity  is  unilateral,  one  leg  will  appear  shorter  than  the  other,  and 
the  child  will  walk  with  a  rolling  limp.  This  condition  should  be  care- 
fully looked  for  when  an  infant  at  the  age  of  fourteen  or  fifteen  months 
has  made  no  especial  attempt  to  walk,  or  when  on  attempting  to  do  so  it 
does  not  succeed. 

Treatment. — As  operative  treatment  has  not  proved  very  successful  in 
these  cases  and  is  not  to  be  employed  until  the  child  is  over  three  years 
old,  the  best  method  of  treatment  is  by  massage.  If  the  disease  is  unilat- 
eral it  should  in  addition  to  the  massage  be  treated  with  a  high  shoe. 

Congenital  Dislocation  of  the  Knee. — Next  in  order  of  frequency  to 
congenital  dislocation  of  the  hip,  but  rare  in  comparison,  is  a  dislocation, 
or  rather  a  partial  dislocation,  of  the  knee.  In  this  condition  the  tibia  is 
found  riding  forw^ard  upon  the  condyles  of  the  femur,  so  that  the  knee- 
joint  can  readily  be  put  into  hyperextension  and  the  toes  made  to  point 
towards  the  forehead. 

Birth  Paralysis. — Birth  paralysis  will  be  considered  in  connection 
with  diseases  of  the  nervous  system.     It  may  be  present  either  in  the 


298  PEDIATRICS. 

muscles  of  the  face  or  in  those  of  the  extremities,  and  is  due  to  pressure 
upon  the  nerves  made  by  the  forceps  or  by  too  great  traction. 


GENERAL.    DISEASES. 

Asphyxia. — The  earliest  pathological  condition  wliich  is  brought  to 
our  notice  at  birth,  and  one  which  recjuires  immediate  treatment,  is  as- 
phyxia. This  condition,  wliich  is  a  failure  of  the  circulatory  mechanism 
to  assume  its  extra-uterine  function  of  oxygenating  the  blood,  endangers 
the  life  of  the  infant  from  carbonic  acid  poisoning.  It  may  arise  either 
from  mechanical  pressure,  as  from  winding  of  the  cord  around  the  neck, 
from  an  incomplete  expansion  of  the  pulmonary  alveoli,  atelectasis,  or 
from  other  causes  connected  with  the  imperfect  oxygenation  of  the  blood, 
of  which  we  have  very  little  knowledge.  In  any  case  the  cause,  if  known, 
must  be  cjuickly  removed.  This  class  of  cases  belongs  so  directly  to 
the  province  of  obstetrics  that  it  need  hardly  be  more  than  mentioned. 
Prompt  measures  for  performing  artificial  respiration,  as  by  Crede's  method, 
and  the  stimulation  of  the  pneumogastric  nerve  by  the  application  of  heat, 
cold,  and  electricity,  should  be  employed. 

Acute  Fatty  Deg-eneration  of  the  Ne-w-Born  (^BuhVs  disease). — An 
affection  which  has  been  called  acute  fatty  degeneration  of  the  new-born 
was  described  by  Buhl  in  1861.  It  is  not  a  disease  of  common  occur- 
rence, and  its  etiology  and  pathology  have  not  yet  been  satisfactorily  de- 
termined. Runge,  of  Dorpat,  has  written  more  fully  on  this  disease  than 
any  other  author,  and  I  am  indebted  to  him  for  the  careful  description 
which  he  has  made  of  the  affection  and  the  literature  which  he  has  col- 
lected concerning  it. 

As  the  anatomical  diagnosis  can  be  made  only  by  using  the  microscope, 
the  disease  has  probably  often  been  overlooked,  and  the  cause  of  death 
^ascribed  on  the  one  hand  to  inanition  and  on  the  other  to  such  especial 
forms  of  hemorrhage  in  the  new-born  as  omphalorrhagia  and  melaena.  If 
the  numerous  causes  of  hemorrhage  from  the  cord  had  been  more  care- 
fully examined  anatomically,  the  disease  would  probably  not  have  re- 
mained so  long  unknown. 

Etiology. — The  etiology  of  acute  fatty  degeneration  of  the  new-born 
is  very  obscure.  The  disease  occurs  in  animals  as  well  as  in  human  beings, 
but  the  investigations  made  by  different  observers  both  on  animals  and  on 
infants  are  so  varied  in  their  results  that  we  cannot  at  present  consider 
that  we  know  much  about  the  cause  of  the  disease.  It  is  significant, 
however,  that  Buhl  in  his  classic  description  of  the  disease  states  emphati- 
cally that  the  vessels  of  the  cord  are  not  affected,  so  that  if  it  is  due  to 
sepsis  the  sepsis  must  have  occurred  in  intra-uterine  life  through  the 
mouth,  the  intestinal  canal,  or  the  umbilicus,  but  without  producing  any 
change  in  the  umbilical  vessels.     This  can  scarcely  be  considered  proba- 


DISEASES   OF   THE   NEW-BORN.  299 

Die.     We  know  nothing  concerning  the  etiology  of  this  disease,  not  even 
whether  it  is  of  intra-  or  extra-uterine  origin. 

Pathological  Anatomy. — The  pathological  conditions  which  represent 
the  disease  consist  of  a  parenchymatous  inflammation,  followed  by  a  fatty 
degeneration  of  the  tissues  of  the  heart,  liver,  and  kidneys,  and  hemorrhages 
in  the  various  organs.  The  post-mortem  examination  of  infants  dying  of 
this  disease,  as  a  rule,  shows  the  following  changes.  The  cadaver  is  livid 
and  usually  icteric.  Hemorrhages  and  oedema  are  often  found  in  the 
skin.  The  umbilicus  and  the  tissues  surrounding  it  are  at  times  stained 
with  blood,  but,  as  a  rule,  are  otherwise  normal.  The  umbilical  vessels 
are  in  most  cases  normal.  These  hemorrhages  are  especially  found  in 
the  dura  and  pia  mater,  in  the  pleura  and  pericardium,  and  in  the  con- 
nective tissue  of  the  mediastinum  :  they  also  occur  in  the  thymus  gland, 
in  the  peritoneum,  in  the  muscles,  and  in  most  of  the  mucous  membranes. 
The  hrain  is  found  to  be  soft,  usually  full  of  blood,  and,  if  icterus  is  present, 
is  stained  yellow.  The  lungs  often  show  hemorrhagic  infarction,  and 
in  the  bronchi  bloody  mucus  or  pure  blood.  The  alveolar  epithelium 
is  in  a  condition  of  fatty  degeneration.  The  muscles  of  the  heart  are 
friable.  In  the  early  stages  they  are  rigid  and  dark  red,  while  in  the 
later  stages  they  become  softer  and  paler.  In  almost  all  of  them  the  pro- 
cess of  fatty  degeneration  is  found.  In  recent  cases  the  tissues  of  the  liver 
are  blood-red,  while  in  the  later  stages  they  are  pale  and  icteric.  The 
liver-cells  contain  fat-drops  and  granules  of  biliary  coloring  matter.  The 
spleen  is  usually  found  to  be  enlarged,  and  its  parenchyma  is  soft  and 
almost  fluid.  Hemorrhages  may  be  found  in  the  walls  of  the  stomaxih 
and  intestine^  and  their  cavities  are  often  found  to  be  filled  with  blood. 
Multiple  hemorrhages  are  found  in  the  parenchyma  of  the  kidney.  The 
cortex  is  swollen  in  the  early  stages,  is  filled  with  blood,  and  is  pale  and 
yellowish.  The  epithelium  of  the  convoluted  tubules  shows  marked  fatty 
degeneration,  and  the  canals  are  often  filled  with  fatty  degenerated  mate- 
rial. The  process  of  fatty  degeneration  does  not  in  all  cases  affect  all  the 
organs.  In  some  the  changes  may  be  absent  or  a  parenchymatous  con- 
dition may  be  present 

Symptoms. — The  infants  who  are  affected  by  this  disease  are  usually 
bom  in  a  condition  of  extreme  asphyxia  without  any  apparent  cause  for 
it.  Attempts  at  resuscitation  are,  as  a  rule,  only  partially  successful,  and 
at  times  not  at  all  so,  many  of  the  cases  dying  at  once.  Diarrhoea  is 
commonly  present,  and  is  often  accompanied  by  blood  from  the  rectum. 
There  is  sometimes  vomiting  of  blood.  Often,  after  the  cord  has  separated, 
there  may  be  a  parenchymatous  hemorrhage,  which,  although  small  in 
amount,  is  at  times  sufficient  to  cause  death.  There  is  usually  a  bluish 
color  of  the  skin,  which  changes  gradually  to  yellow  or  a  mixture  of  yel- 
low and  blue.  Hemorrhages  occur  frequently  in  the  skin,  the  conjunctivae, 
the  mucous  membranes  of  the  mouth  and  nose,  and  sometimes  the  outer 
ear.     Icterus  may  be  present  in  these  cases,  and  at  times  may  become 


300  PEDIATRICS. 

intense.  Sometimes  oedema  occurs,  and  without  any  noticeable  rise  of 
temperature  there  may  be  a  rapid  collapse,  followed  by  death,  commonly 
within  the  first  fourteen  days  of  life.  These  symptoms  are  not  always  so 
well  marked  as  have  been  just  described.  The  external  hemorrhages  may 
not  occur,  and  the  cyanosis,  slight  at  first,  may  rapidly  increase  and  be 
followed  by  sudden  death.  This  sometimes  happens  so  quickly  that  we 
are  reminded  of  the  conditions  which  are  met  with  in  case  of  death  by 
violence. 

Diagnosis. — A  definite  diagnosis  cannot  be  made  without  a  careful 
microscopic  examination.  This  disease  must  not  be  confounded  with  phos- 
phorus or  arsenic  poisoning,  in  which  the  organs  undergo  similar  path- 
ological changes.  The  history  of  the  case  and  a  chemical  examination 
of  the  organs  will  enable  one  to  eliminate  these  other  causes  of  fatty  de- 
g,eneration.  The  differential  diagnosis  between  this  disease  and  cases  of 
sepsis  in  which  hemorrhages  and  parenchymatous  changes  occur  is  very 
difficult.  When  the  vessels  of  the  cord  are  affected,  we  must  in  most 
cases  consider  the  cause  to  be  septic ;  when  the  cases  occur  in  groups,  as 
is  seen  at  times  in  hospitals  or  other  places  where  a  number  of  infants 
are  gathered  together,  this  same  cause  must  be  suspected ;  also  when 
putrefactive  changes  have  progressed  rapidly  in  the  cadaver  we  should  be 
inclined  to  regard  the  case  as  one  of  septic  poisoning,  as  these  changes, 
according  to  Hecker,  do  not  occur  in  the  specific  disease  called  fatty 
degeneration. 

Fatty  degeneration  at  times  simulates  so  closely  the  appearances 
caused  by  death  from  suffocation  that  its  presence  becomes  a  question 
of  great  importance  from  a  medico-legal  stand-point.  The  cyanosis,  the 
condition  of  the  lungs,  and  the  ecchymoses,  also  the  absence  macroscopi- 
cally  of  other  organic  changes,  can  easily  suggest  suffocation.  For  this 
reason  in  all  cases  of  death  among  new-born  children  where  there  is  a 
suspicion  of  asphyxia,  a  careful  microscopic  examination  should  be  made 
of  all  the  organs. 

Prognosis. — The  prognosis  in  this  disease  is  very  unfavorable ;  all 
the  cases  in  which  the  symptoms  are  pronounced  die.  It  is  possible 
that  the  milder  forms  of  the  disease  can  recover,  but  as  yet  we  do  not 
know  enough  about  this  class  of  cases  to  state  what  proportion  of  them 
lives. 

Treatment. — From  what  has  been  said  concerning  this  disease  it  Avill 
be  readily  understood  that  the  treatment  is  usually  unsuccessful.  Stimu- 
lants should  be  used  and  the  food,  carefully  regulated. 

Infectious  Hsemog-lobineeraia  of  the  New-born  (^infectious  hcemo- 
globinuria ;  WinheVs  disease). — Infectious  haBmoglobinaemia  is  an  affec- 
tion which  is  met  with  in  new-born  infants  usually  in  the  early  days 
of  life,  and,  as  a  rule,  arises  as  an  endemic  disease  in  hospitals.  A 
specific  micro-organism  has  not  yet  been  discovered,  yet  the  endemic 
character  of  the  malady  and  the   changes  which  are  produced  in  the 


DISEASES  OF  THE  NEW-BORN.  301 

blood  warrant  us  in  supposing  that  it  is  an  infectious  disease.  Al- 
though it  had  been  described  at  an  earher  date,  yet  the  most  systematic 
description  of  it  which  had  appeared  up  to  the  year  1879  was  that  by 
Winckel,  who  in  that  year  reported  twenty-three  cases  of  an  endemic 
affection  observed  by  him  at  the  Dresden  Lying-in  Hospital.  The  disease 
was  characterized  by  extreme  cynanosis,  icterus,  haemoglobinuria,  somno- 
lence, rapid  collapse,  and  the  absence  of  fever.  Although  in  many  re- 
spects it  resembled  closely  the  acute  fatty  degeneration  described  on  page 
298,  yet  it  had  such  characteristic  symptoms  and  conditions  of  its  own 
that  for  the  present  it  should  be  kept  separate  from  that  disease.  We  are 
indebted  to  Runge  for  a  description  of  this  disease.  An  analysis  of  Winckers 
cases  shows  that  it  usually  begins  on  the  fourth  day  of  life,  and  that  it 
may  attack  strong,  well-developed  infants.  The  course  of  the  affection  is 
very  rapid,  its  average  duration  being  about  thirty-two  hours.  Twenty- 
five  and  a  half  per  cent,  of  all  the  children  born  at  the  time  when  this 
epidemic  occurred  had  the  disease,  and  of  these  nineteen  per  cent.  died. 

Etiology. — The  etiology  of  this  disease  is  obscure.  Winckel  had  the 
organs  carefully  examined  chemically  for  poisons,  such  as  phosphorus, 
arsenic,  and  chlorate  of  potash,  but  with  negative  results.  Examinations 
in  regard  to  carbolic  acid  poisoning  have  also  been  made  in  these  cases, 
with  negative  results.  In  studying  the  literature  of  this  disease  we  find  a 
number  of  observations  by  different  authors.  Bigelow  described  an  epi- 
demic at  the  Boston  Lying-in  Hospital  in  which  the  chief  symptoms 
were  a  dark  color  of  the  skin  resembling  somewhat  that  produced  by  the 
administration  of  nitrate  of  silver,  hsemoglobinuria,  diphtheritic  deposits 
on  certain  of  the  mucous  membranes,  and  dark  brown  faecal  dejections. 
In  this  epidemic  ten  infants  were  attacked  and  eight  died,  the  average  du- 
ration of  the  disease  being  five  days.  In  one  of  these  cases  phlebitis 
umbilicalis  occurred.  Similar  cases  have  been  reported  by  Parrot  and 
Herz,  in  which  the  urine  was  brown  and  strongly  tinged  with  blood,  and 
the  kidneys  and  liver  showed  the  condition  of  fatty  degeneration. 

Epstein,  of  Prague,  mentions  similar  cases  in  which  prominent  features 
were  the  thickening  of  the  blood,  which  made  it  impossible  to  get  a  drop 
to  examine,  and  the  dark  brown-red  color  of  the  urine.  Epstein  thinks 
that  this  disease  is  a  septic  process  which  probably  starts  in  the  gastro- 
enteric tract.  He  believes  that  he  can  controvert  the  apparent  absence 
of  fever  by  the  fact  that  in  the  diseases  of  new-born  infants  great  and 
sudden  variations  of  temperature  occur,  and  in  consequence  the  tem- 
perature, for  its  record  to  be  of  value,  should  be  taken  very  often. 
Whether  this  is  so  or  not,  the  disease  has  certain  peculiarities,  pointing  in 
some  cases  to  an  apparent  relation  with  sepsis,  and  in  others  to  acute 
fatty  degeneration.  The  obscurity  as  to  the  etiology  of  the  disease  has 
been  rendered  still  greater  by  the  incomplete  examinations  which  have 
been  made  of  this  class  of  cases,  with  the  exception  of  those  by  Winckel 
and  Birch-Hirschfeld. 


302  PEDIATRICS. 

Pathological  Anatomy.  —  A  careful  post-mortem  examination  of 
Winckel's  cases  showed  that  there  was  cyanosis  of  the  external  and  in- 
ternal organs.  Except  in  one  instance,  no  pathological  condition  of  the 
vessels  of  the  cord  was  described.  The  cortex  of  the  hklney  was  fomid  to 
be  wider  than  normal,  to  be  of  a  brownish  color,  and  to  present  numerous 
minute  hemorrhages.  In  some  places  the  pyramids  were  entirely  black-red 
in  color,  and  in  other  places  numerous  black  streaks  were  found  which  con- 
verged to  the  papillae.  This  color  was  caused  by  the  filling  of  the  straight 
tubules  with  granules  of  haemoglobin.  Intact  erythrocytes  were  never 
found.  The  bladder  was  found  to  contain  greenish-brown  urine.  The 
spleen  was  strikingly  enlarged  and  hard.  Its  length  was  about  7.5  cm. 
(3  inches),  and  its  weight  25  grammes  (f  ounce).  It  was  black-red  in 
color,  and  on  section  the  surface  was  smooth.  Microscopic  examination 
showed  a  considerable  accumulation  of  brownish  coloring  matter,  partly 
free  and  partly  in  the  pulp-cells. 

In  addition  to  these  appearances  in  special  organs,  minute  hemor- 
rhages were  found  in  nearly  all  the  organs,  but  especially  in  the  pleura, 
pericardium,  endocardium,  mucous  membranes  of  the  stomach  and  small 
intestine,  and  kidney :  they  were  also  found  in  the  dura  and  pia  mater 
and  under  the  capsule  of  the  liver.  The  lymph-follicles  were  swollen, 
especially  Peyer's  patches  and  the  mesenteric  lymph-glands.  A  micro- 
scopic examination  showed  fatty  degeneration  of  many  important  organs, 
especially  the  liver,  and  at  times  of  the  muscles  of  the  heart.  The  bac- 
teriological examinations  were,  as  a  rule,  negative,  especially  as  regards 
the  tissues  of  the  intestine.  Clumps  of  bacteria  were  found  only  once  in 
the  liver  and  once  in  the  kidney. 

Symptoms. — The  first  symptoms  were  generally  restlessness  and  cyano- 
sis, not  only  of  the  face  but  also  of  the  body  and  extremities,  and  especi- 
ally of  the  back.  The  color  increased  progressively  until  it  became  a  deep 
blue.  To  this  was  added  an  icteric  color,  which  when  death  did  not 
-occur  within  twenty-four  hours  became  very  marked.  The  respiration 
was  rapid ;  the  pulse  Avas  not  especially  increased  in  rate.  The  rectal 
temperature  never  rose  higher  than  38.1°  C.  (100.6°  F.).  The  skin 
generally  felt  cool.  Vomiting  and  diarrhoea  occurred  in  some  cases.  The 
most  striking  symptom  was  the  appearance  of  the  urine.  It  had  a  pale- 
brownish  color,  and  was  passed  frequently,  and  often  with  considerable 
straining.  An  examination  showed  that  the  color  was  due  not  to  bile, 
but  to  haemoglobin.  In  the  sediment  were  found  numerous  epithelial 
cells  from  the  walls  of  the  kidney,  granular  casts  with  blood-corpuscles 
adherent  to  them,  micrococci,  masses  of  detritus,  and  urate  of  ammonia. 
A  small  quantity  of  albumin  was  present.  Later  in  the  disease  con- 
vulsions occurred,  followed  rapidly  by  death.  It  was  noticed  that  if  the 
skin,  where  the  cyanosis  was  most  marked,  was  scratched  and  then  pressed 
hard,  a  tenacious,  almost  black-brown  fluid  exuded.  An  examination  of 
the  blood  showed  a  marked  increase  of  leucocytes  and  numerous  granules. 


DISEASES   OF   THE   NEW-BORN.  303 

In  other  cases  besides  those  of  WinckePs  in  which  the  blood  was  ex- 
amined the  condition  was  found  to  be  one  of  haemoglobinaemia.  The  per- 
centage of  hgemoglobin  was  high,  and  free  hsemoglobin  was  found  in  the 
blood-serum,  while  the  erythrocytes  were  greatly  reduced  in  number,  at 
times  amounting  to  only  1,700,000  or  even  less. 

Diagnosis. — The  resemblance  of  this  disease  to  acute  fatty  degeneration 
of  the  new-born  is  very  striking.  Most  of  the  symptoms  are  common  to 
both  diseases.  Large  hemorrhages  are  also  not  uncommon  in  this  disease, 
but  are  not  so  marked  as  in  acute  fatty  degeneration.  The  striking  points 
of  difference  are  the  presence  of  hsemoglobinuria  and  the  fact  that  large 
numbers  are  affected  at  the  same  time  in  infectious  hsemoglobinaemia, 
while  these  conditions  have  not  been  found  to  occur  in  acute  fatty  de- 
generation. 

Treatment. — The  treatment  should  be  the  administration  of  oxygen 
and  stimulants,  and  forced  feeding  by  means  of  a  dropper  where  the 
infant  is  too  weak  to  suck. 

Hemorrhag-e  in  Early  Life. — Spontaneous  hemorrhage  occurring  at 
some  period  during  the  early  years  of  life  is  not  uncommon.  These 
hemorrhages  may  occur  either  in  the  skin  or  from  some  trifling  traumatic 
lesion,  or  they  may  take  place  in  various  internal  organs,  and  especially 
from  the  mucous  membrane  of  the  mouth  and  the  gastro-enteric  tract. 
A  definite  division  of  this  class  of  cases  has  never  been  thoroughly  made, 
so  that  the  subject  has  always  been  somewhat  involved  in  obscurity.  The 
probability  is  that  these  spontaneous  hemorrhages  are  simply  symptomatic 
of  different  specific  infections.  The  propriety  of  separating  cases  of 
spontaneous  hemorrhage  which  occur  in  the  early  days  and  weeks 
of  life  from  those  which  arise  later  has  been  shown  by  Townsend. 
He  has  by  a  series  of  observations'  corroborated  the  now  generally 
accepted  opinion  that  the  hemorrhages  which  occur  in  the  new-born 
should  be  separated  from  those  met  with  in  connection  with  the  haemo- 
philia of  a  later  period  of  childhood  and  of  adults-.  He  has  cahed  this 
disease  the  hemorrhagic  disease  of  the  new-born.  The  hemorrhages  which 
occur  in  new-born  infants  are  so  general  in  their  distribution,  and  yet  so 
uniform  in  their  general  symptoms,  that  they  can  well  be  classed  under 
this  one  heading.  These  hemorrhages  occurring  in  the  early  weeks  of 
life  run  a  definite  course,  and  end  in  death  or  in  complete  recovery. 
The  self-limited  nature  of  this  affection  corresponds  to  what  is  seen  in 
the  acute  infectious  diseases,  and  suggests  a  relationship  to  them.  The 
hemorrhage  may  arise  from  the  gastro-enteric  tract,  from  the  mouth, 
the  nose,  or  the  umbilicus,  also  from  the  skin,  and  in  the  latter  case  may 
show  itself  in  the  form  of  ecchymoses.  Again,  it  may  occur  in  the  form 
of  hemorrhages  in  the  abdominal  cavity,  the  meninges  of  the  brain,  the 
pleura,  the  lung,  and  the  thymus  gland.  Townsend  has  collected  fifty 
cases  of  this  disease,  and  has  tabulated  the  sources  of  the  hemorrhage, 
as  follows  ; 


304  PEDIATRICS. 

Locality.  Cases. 

Intestines 20 

Stomach 14 

Mouth ■ 14 

Nose : 12 

Umbilicus 18 

Ecchjanosis  in  skin 21 

Scratch  of  skin 1 

Cephalhaematoma 3 

Meninges 4 

Abdominal  cavity 2 

Pleural  cavity 1 

Lung 1 

Thymus  gland 1 

From  the  gastro-enteric  tract,  nose,  and  umbilicus,  accompanied  by 

ecchymosis  in  the  skin 3 

From  the  gastro-enteric  tract  alone  .    19 

From  the  umbilicus  alone 3 

From  ecchymosis  in  the  skin  alone 6 

Ritter,  at  the  Prague  Foundling  Hospital,  has  also  noticed  a  great  pre- 
ponderance of  cases  occurring  in  hospital  deliveries  over  those  which  were 
met  with  outside  of  the  hospitals. 

In  fourteen  of  these  fifty  cases  the  temperature  was  carefully  observed, 
and  in  all  hut  two  was  found  to  be  elevated  at  first  from  38.3°  C.  (101° 
F.)  to  39.5  C.  (103.1  F.),  and  in  one  case  to  41.1°  C.  (106°  F.).  After  the 
cessation  of  the  hemorrhages  the  temperature  was  normal,  and  often 
subnormal. 

Some  of  the  cases  occur  in  infants  in  whom  a  strong  family  history  of 
syphilis  can  be  obtained,  and  confirmatory  evidence  of  this  etiological 
factor  is  obtained  in  the  amelioration  or  cure  which  follows  vigorous  anti- 
syphilitic  treatment,  whereas  the  same  treatment  in  infants  in  whom  no 
evidence  of  syphilis  exists  does  not  influence  the  hemorrhagic  condition. 

A  second  class  of  cases  is  those  in  which  the  disease  is  in  all  proba- 
bility due  to  infection  through  the  cord,  mouth  or  intestines.  The  child 
becomes  restless  and  refuses  to  nurse.  The  temperature  rises,  sometimes 
as  high  as  40°  C.  (104°  F.),  the  pulse  becomes  rapid  and  full,  then  weak 
and  thready,  and  the  signs  of  hemorrhage  soon  appear,  and  death  follows 
in  a  few  hours  or  days,  according  to  the  severity  of  the  infection  or  the 
extent  of  the  hemorrhage.  Many  of  these  cases  have  been  examined 
bacteriologically  and  have  shown,  in  the  blood  and  organs,  pure  or  mixed 
cultures  of  a  variety  of  different  bacteria,  such  as  the  streptococcus, 
staphylococcus,  pneumococcus,  B.  pyocyaneus,  B.  lactis  aerogenes,  B.  of 
Gaertner,  a  diplococcus  resembling  the  pneumococcus,  a  bacillus  resem- 
bling that  of  Friedlander,  and  the  bacillus  described  by  Kolb  as  occurring 
in  purpura  hgemorrhagica. 

There  is  a  third  class  which  is  very  obscure  as  regards  its  etiology. 
Fatal  hemorrhages  occur  without  any  alteration  of  temperature  and  with 
negative  blood  cultures.  ' 


DISEASES    OF   THE   NEW-BORN.  305 

The  mortality  in  Townsend's  cases  was  62  per  cent.  The  bleeding  first 
showed  itself  in  all  but  three  within  the  first  seven  days  of  life,  the  ex- 
ceptions being  on  the  eighth,  ninth,  and  fourteenth  days.  The  hemor- 
rhage in  the  majority  of  these  cases  began  on  the  second  or  third  day, 
thirteen  starting  on  the  second  and  sixteen  on  the  third  day,  while  only 
eight  began  on  the  fourth  and  two  on  the  first  day.  One-half  of  the 
fatal  cases  lasted  one  day  or  less,  and  all  the  others  died  within  a  week, 
except  one  case,  in  which  death  took  place  from. the  effects  of  the  hemor- 
rhage on  the  eighth  day  and  several  days  after  the  bleeding  had  ceased. 
The  cases  that  lived  recovered  within  nine  days,  and  two-thirds  of  them 
within  five  days. 

The  cases  of  pseudomenstruation  which  occur  not  uncommonly  in 
the  early  days  of  life  should  not  be  included  in  the  cases  which  are 
classed  under  the  heading  of  hemorrhagic  disease.  The  hemorrhagic 
disease  is  apparently  infectious  and  is  a  general  and  not  a  local  one,  and 
is  found  more  frec|uently  in  hospitals  than  in  private  practice.  This  fact 
is  well  exemplified  by  comparing  the  percentage  of  hemorrhagic  cases 
which  occurred  among  7225  infants  observed  in  the  Boston  Lying-in  Hos- 
pital and  its  out-patient  department.  The  percentage  of  the  disease  occur- 
ring in  the  hospital  itself  was  0.57,  while  0.10  represented  the  proportion 
outside  of  the  hospital.  In  Townsend's  fifty  cases  the  proportion  of  females 
to  males  Avas  as  20  to  30.  In  four  of  his  cases  the  hemorrhage  took  place 
in  several  other  places  as  well  as  at  the  base  of  the  cord,  but  the  patients 
recovered  and  the  cord  separated,  in  one  case  in  two  days  and  in  the  other 
three  in  four  days  after  the  cessation  of  the  disease,  without  a  fresh 
hemorrhage  occurring. 

In  connection  with  the  hemorrhage  which  occurs  in  the  gastro-entenc 
tract,  the  tar-color  of  the  intestinal  dejections,  arising  from  the  hemor- 
rhage taking  place  high  up  in  the  intestine,  is  noticeable.  The  resem- 
blance of  the  color  of  the  dejections  to  that  of  meconium  may  cause  the 
disease  to  be  overlooked.  A  slightly  pink  tinge  on  the  napkin  around  the 
dejection  is  often,  however,  seen,  and  where  there  is  a  doubt  as  to  whether 
the  stain  is  from  blood  or  not,  it  can  usually  be  determined  by  means  of 
the  microscope.  When  the  corpuscles  have  become  disintegrated,  as  at 
times  occurs,  the  haemin  crystals  may  be  recognized  by  means  of  a  simple 
test  which  we  shall  speak  of  later.  The  post-mortem  examination  which 
was  made  in  nine  of  these  cases  throws  no  additional  light  upon  the  nature 
of  the  affection.  The  source  of  the  hemorrhage  was  found,  but  in  no  case 
were  there  any  gross  lesions  of  the  mucous  membrane  or  the  blood- 
vessels. In  all  these  cases  the  infants  looked  very  anaemic.  In  one  case 
cultures  were  made  by  Professor  Councilman  from  the  blood,  with  nega- 
tive results.  We  do  not  know  what  the  cause  of  this  disease  is,  but  it  is 
probable  that  in  the  great  majority  of  cases  it  has  an  infectious  origin. 

The  following  case  is  especially  interesting,  as  it  shows  an  unusual 
result  of  the  blood  examination  : 

20 


306  PEDIATRICS. 

The  infant  was  three  daj^s  old,  and  presented  a  blanched  appearance  of  the  skin, 
with  stains  on  the  napkin  around  the  intestinal  discharges.  These  stains  were  ex- 
amined in  the  following  way.  A  drop  of  the  semi-liquid  dejection  was  mixed  with  a 
little  glacial  acetic  acid  and  a  few  crystals  of  common  salt  on  a  glass  slide  and  heated 
to  boiling.  On  drying  the  preparation  and  examining  it  under  the  microscope,  the 
dark  rhombic  crystals  of  hsemin  were  easily  recognized,  showing  us  that  we  were 
dealing  with  a  case  of  hemorrhage  taking  place  probably  high  up  in  the  intestine. 
An  examination  of  the  blood  by  Dr.  Wentworth  gave  the  following  results  :■ 

Erythrocytes 0,245,000 

Haemoglobin 125  per  cent. 

The  blood  spread  very  thickly  and  stained  poorly,  but  the  polynuclear  leucocytes 
appeared  greatly  in  excess  of  the  other  forms. 

The  cases  which  are  commonly  designated  as  meloena  neonatorum 
should  be  classed  under  this  heading  of  the  hemorrhagic  disease  of  the 
new-born. 

An  interesting  case  of  this  disease  was  seen  in  consultation  with  Dr. 
Bush : 

A  male  infant,  apparently  healthy  at  birth,  developed,  on  the  third  day  of  its  life, 
ecchymoses  on  its  head,  groins,  and  one  foot.  There  was  also  hemorrhage  from  the 
upper  part  of  the  intestine  on  the  fifth  and  sixth  day,  the  dejections  being  tar-colored 
from  altered  blood  which  simulated  meconium.  On  the  fifth  day  the  child  developed 
a  marked  paralysis  of  the  left  side  of  the  face,  and  to  a  less  degree  of  the  left  arm  and 
leg,  presumably  from  a  meningeal  hemorrhage.  On  the  seventh  day  of  the  disease  the 
hemorrhage  had  apparently  ceased,  as  the  paralysis  was  beginning  to  disappear.  On 
the  twelfth  day  the  paralysis  of  the  left  arm  and  leg  had  improved  :  there  was,  how- 
ever, still  some  paralysis  on  the  left  side  of  the  face,  but  this  did  not  continue  to  any 
great  extent,  and  in  the  third  and  fourth  weeks  decided  improvement  took  place  in  the 
child's  condition,  and  there  were  no  longer  any  evidences  of  hemorrhage  nor  any  paral- 
ysis. The  infant  improved  rapidly  during  its  first  year,  and  became  healthy  and  strong. 
It  learned  to  walk  and  talk  rather  later  than  usual,  but  at  four  years  of  age  was  in 
a  normal  condition  both  mentally  and  physically. 

We  have  met  with  a  number  of  cases  in  which  these  hemorrhages  oc- 
curred which  varied  greatly  as  to  extent  and  persistence.  The  cases  in 
which  umbilical  hemorrhage  was  present  showed  this  same  tendency  to 
self-limitation,  and  could  be  distinguished  from  those  which  are  classed 
under  haemophilia.  In  fact,  it  is  probable  that  most  cases  of  umbilical 
hemorrhage  are  caused  by  infection  and  are  not  especially  connected  with 
haemophilia. 

The  following  case  of  umbilical  hemorrhage  in  a  male  illustrates  what 
has  been  said  concerning  the  desirability  of  separating  the  hemorrhages 
taking  place  in  the  early  days  and  weeks  of  infancy  from  those  which 
occur  later  and  in  childhood : 

The  parents  of  the  infant  were  well  and  strong,  and  were  Russian  Poles.  They  had 
another  child,  eighteen  months  old,  which  was  healthy.  The  mother  had  never  had 
any  miscarriages,  and  stated  that  her  parents  were  healthy,   as  were  also  those  of  the 


DISEASES    OF   THE   NEW-BORN.  307 

father.  The  labor  was  a  normal  one,  the  child  presenting  in  the  first  position,  and 
nothing  abnormal  was  noticed,  except  that  the  placental  end  of  the  cord  continued  to 
bleed  quite  freely  notwithstanding  the  application  of  two  ligatures.  On  the  day  follow- 
ing the  delivery  the  mother  and  infant  were  both  doing  well  ;  the  latter  showed  slight 
signs  of  icterus,  but  nursed  well,  and  the  former  had  plenty  of  good  breast-milk.  The 
infant  continued  to  thrive,  except  that  there  was  a  slight  hemorrhage  around  the  inser- 
tion of  the  cord,  which  fell  off  on  the  eighth  day.  After  the  separation  of  the  cord  a 
slight  hemorrhage  from  the  umbilicus  continued.  On  the  thirteenth  day  the  hemor- 
rhage increased,  and  became  very  extensive.  The  infant  was  then  found  to  he  de- 
cidedly jaundiced,  though  not  deeply  so.  It  was  nursing  well,  but  looked  thin  and  puny. 
Nothing  abnormal  was  discovered  in  the  physical  examination.  Pale,  watery-looking 
blood  was  oozing  from  the  umbilicus,  and  quite  a  large  cloth  had  been  soaked  with  the 
blood,  giving  evidence  of  a  considerable  hemorrhage.  The  umbilicus  was  plugged  with 
small  pieces  of  lint  soaked  in  perchloride  of  iron,  firmly  compressed  by  a  bandage, 
and  alternate  drop  doses  of  fluid  extract  of  ergot  and  tincture  of  chloride  of  iron  were 
ordered  to  be  given  three  times  a  day. 

On  the  fifteenth  day  the  hemorrhage  had  somewhat  abated,  but  it  was  not  thought 
advisable  to  remove  the  bandage  ;  the  ergot  was  omitted,  on  account  of  nausea  and 
vomiting.  On  the  sixteenth  day  the  infant  was  reported  to  have  vomited  and  cried  a 
great  deal,  and  the  plugs  of  lint  had  been  forced  out  of  the  umbilicus,  leaving  a  bleed- 
ing surface  ;  the  umbilicus  was  then  tamponed  with  Monsel's  solution  of  subsulphate 
of  iron  ;  the  tincture  of  chloride  of  iron  was  omitted,  as  it  caused  vomiting.  The 
hemorrhage  then  lessened  and  at  times  ceased.  On  the  seventeenth  day  the  older 
child  pricked  the  infant's  lip  with  a  pin,  and  on  the  eighteenth  day  the  lip  was  found 
to  be  still  bleeding.  The  point  of  hemorrhage  was  cauterized  with  a  stick  of  nitrate 
of  silver.  This  controlled  the  flow  of  blood  for  about  two  hours,  when  it  returned 
and  continued.  Compression  of  the  lip  finally  stopped  the  bleeding  on  the  twenty- 
fourth  day.  On  the  nineteenth  day  the  hemorrhage  had  ceased  at  the  umbilicus,  and 
the  child  continued  to  nurse  well.  On  the  twenty-ninth  day  the  bandage  and  lint  were 
removed  from  the  umbilicus,  and  the  abdomen  was  washed.  There  was  no  bleed- 
ing ;  the  child  looked  better,  and  there  was  not  so  much  icterus.  On  the  thirtieth 
day  the  infant  was  reported  to  be  perfectly  well.  It  continued  to  thrive  from  this  time, 
with  no  recurrence  of  the  hemorrhage.  On  the  sixtieth  day,  although  we  advised  that 
the  operation  should  not  be  performed,  the  infant,  in  accordance  with  the  Jewish  cus- 
tom, was  circumcised.  We  were  present  at  the  circumcision,  to  see  if  the  hemorrhage 
would  be  easily  arrested.  The  circumcision  was  performed  without  accident,  and  the 
hemorrhage  was  immediately  arrested  by  a  weak  solution  of  iron.  From  this  time 
there  was  no  hemorrhage,  and  the  child  continued  to  be  strong  and  well. 

This  case  is  an  instance  of  the  self-limitation  of  the  hemorrhagic  disease  of  the  new- 
born, since,  although  it  was  a  pronounced  case  of  umbilical  and  general  hemorrhage  at 
the  beginning  of  the  infant's  life,  this  tendency  had  ceased  by  the  end  of  the  second 
month,  as  was  evidenced  by  the  ready  control  of  the  hemorrhage  after  the  circumcision. 

In  another  case  which  came  under  our  notice  the  hemorrhage  took  place  from  the 
umbilicus  in  the  early  days  of  life  at  the  time  of  the  separation  of  the  cord,  and  was 
completely  uncontrolled  even  by  ligatures  passed  around  needles  introduced  through  the 
skin  of  the  abdomen  on  either  side  of  the  umbilicus.     This  case  eventually  recovered. 

In  none  of  these  cases  has  a  tendency  to  bleeding  developed  in  later  life. 

At  times  we  meet  with  what  are  very  mild  cases  of  this  disease.  The 
only  symptoms  may  be  restlessness  and  a  rise  in  temperature,  followed  in 
twenty-four  or  thirty-six  hours  by  the  appearance  of  minute  hemorrhagic 


308  PEDIATRICS. 

maculcB  in  different  parts  of  the  body.  The  hemorrhages  gradually  dis- 
appear and  the  temperature  falls  to  normal  in  the  course  of  a  few  days. 

Treatment. — The  treatment  of  hemorrhagic  diseases  of  the  nexv-born 
unfortunately  is  usually  inefficient.  Gelatin  has  recently  been  tried.  It 
is  especially  indicated  in  hemorrhage  from  the  stomach  and  intestines,  and 
in  these  cases  should  be  given  by  mouth.  A  one-  or  two-per-cent.  solu- 
tion given  frec|uently  and  in  as  large  amounts  as  can  be  tolerated  will 
sometimes  arrest  the  hemorrhage.  Commercial  gelatin  usually  contains 
the  bacillus  of  tetanus,  and  its  use  in  subcutaneous  injections  is  therefore 
accompanied  by  great  risk.  Solutions  of  from  one-quarter  to  one-half 
grain  of  suprarenal  extract  given  by  mouth  have  been  recommended.  If 
given  at  all,  the  physiological  effects  should  be  carefully  watched.  Applied 
locally  to  accessible  bleeding  points,  it  is  of  undoubted  value.  Caustics, 
such  as  nitrate  of  silver  and  chromic  acid,  and  astringents  may  be  used 
for  local  applications.  Careful  feeding,  the  maintenance  of  bodily  tem- 
perature, and  stimulants  in  case  of  threatened  collapse  are  important 
points  in  the  management  of  all  forms  of  hemorrhagic  disease. 

Sclerema  Neonatorum. — Sclerema  neonatorum  is  a  disease  which 
occurs  in  the  early  days  of  life,  and  usually  among  those  who  are  born  in 
the  midst  of  exceedingly  poor  hygienic  surroundings  and  in  cold  weather. 
It  is  characterized  by  a  hardening  of  the  skin  and  the  subcutaneous  cellular 
tissue  and, by  a  great  reduction  in  the  temperature.  The  tissues  continue 
to  grow  cooler  and  harder  until  death,  which  occurs  usually  about  the 
ninth  day.     It  is  a  rare  and  exceedingly  fatal  disease. 

It  should  not  be  looked  upon  as  a  local  disease  of  the  skin,  but  as  some 
obscure  constitutional  affection  of  the  respiratory  and  circulatory  systems, 
as  shown  by  the  shallow  respirations  and  the  diminished  activity  of  the 
circulation. 

A  number  of  cases  of  this  disease  have  been  reported  in  Europe,  and 
several  in  this  country,  notably  by  Osier.  Some  investigators  think  that 
they  have  found  characteristic  changes  in  the  skin.  The  observations  of 
Northrup,  however,  who  published  the  first  report  of  a  typical  case  of 
this  kind  in  America,  seem  to  show  that  there  is  no  definite  lesion  of  the 
skin.  Northrup  made  a  careful  study  of  his  case,  and  has  plainly  shown 
by  sections  of  the  skin  compared  with  normal  control  specimens  that  the 
histology  of  the  disease  does  not  reveal  any  change  which  can  be  regarded 
as  characteristic.  This  case  embodied  every  feature  of  the  typical  scle- 
rema of  the  new-born.  The  infant  was  a  foundling,  born  in  a  wretched, 
damp  habitation,  and  was  the  weaker  of  twins.  On  the  fifth  day  of  its 
life  the  feet  were  found  to  be  swollen,  and  soon  began  to  give  on  palpa- 
tion a  feeling  of  hardness  like  that  of  a  board.  This  condition  soon 
spread  upward  to  the  legs,  thighs,  hips,  shoulders,  arms,  face,  and  scalp. 
The  whole  body  felt  as  though  it  were  half  frozen.  The  temperature 
in  the  rectum  was  under  35°  C.  (95°  F.).  The  infant  died  on  the  ninth 
day. 


DISEASES   OF   THE   NEW-BORN.  309 

Symptoms. — Soon  after  birth,  spots  of  circumscribed  hardness  appear 
on  the  skin.  These  spots  soon  become  diffuse,  and  the  disease,  starting, 
as  it  usuaUy  does,  in  the  feet  or  the  calves  of  the  legs,  passes  up  the  thighs 
to  the  trunk.  It  may,  however,  first  appear  upon  the  face  and  upper 
extremities,  though  not  commonly.  The  skin  is  waxy  and  glistening,  and 
is  hard  and  cold  ;  the  limbs  become  thick,  stiff,  and  misshapen.  The  in- 
fant soon  grows  weak  and  somnolent,  and  refuses  to  take  its  food  ;  the 
breathing  becomes  rapid  and  superficial,  the  voice  is  weak  and  whimper- 
ing, and  the  pulse  small  and  retarded.  Towards  the  end  of  life  a  discharge 
of  bloody  serum  from  the  mouth  and  nose  often  occurs,  and  death  lakes 
place  seemingly  from  inanition. 

Treatment. — There  is  no  treatment  which  has  been  especially  success- 
ful in  this  disease,  but  the  affection  should  be  recognized  at  once,  and  ener- 
getically treated  with  inunctions  of  hot  oil  and  by  massage  and  stimulants. 

CEdema  Neonatorum. — CEdema  neonatorum  is  a  rare  disease,  which 
some  authorities  describe  as  distinct  from  sclerema  neonatorum,  the  chief 
difference  being  that  the  skin  pits  on  pressure  and  is  not  so  hard  as  in  the 
latter  disease.  The  general  symptoms  of  the  two  diseases  resemble  one 
another  very  closely. 

Icterus  Neonatorum. — Icterus  occurs  from  a  number  of  causes  in  the 
new-born  infant  as  symptomatic  of  diseases,  such  as  have  been  described 
under  acute  fatty  degeneration,  infectious  hgemoglobinaeinia,  and  congenital 
obliteration  of  the  bile-ducts.  There  is  one  form,  however,  which  is  of  so 
slight  a  grade  and  is  characterized  by  so  entire  an  absence  of  pathological 
symptoms  that  it  is  usually  looked  upon  as  representing  a  physiological 
condition  occurring  in  the  transition  from  the  intra-uterine  to  the  extra- 
uterine circulatory  mechanism.  It  is  to  this  condition  that  the  name 
icterus  neonatorum  is  given.  It  occurs  in  the  first  few  days  of  life,  and 
may  not  entirely  disappear  for  several  weeks.  The  most  common  time  for 
it  to  begin  is  from  the  second  to  the  third  day,  and,  according  to  its  in- 
tensity, the  usual  time  of  its  continuation  is  from  eight  to  fourteen  days. 
It  is  not  accompanied  by  any  special  symptoms.  The  conjunctivae  are 
somewhat  tinged  with  yellow  in  a  certain  number  of  cases,  but  it  does  not 
always  affect  the  color  of  the  faecal  discharges  or  appear  in  any  quantity 
in  the  urine. 

A  severer  form  occurs,  in  which  the  icterus  is  more  pronounced  and  the 
temperature  is  elevated  for  several  days.  These  cases  are  very  likely  due 
to  infections  of  the  common  duct,  or  its  contributing  ducts,  originating 
either  in  the  cord  or  intestines.  The  stools  may  become  light  colored, 
and  the  urine  very  dark,  from  the  elimination  of  bile  pigment. 

Careful  examinations  of  the  blood  in  cases  of  icterus  neonatorum  fail 
to  show  any  changes  beyond  what  would  be  expected  in  the  early  transi- 
tional stage  of  blood  development  commonly  found  at  this  age.  Plate  II., 
facing  page  75,  represents  a  healthy  male,  ten  days  old,  with  the  charac- 
teristic pigmentation  of  this  disease. 


310  PEDIATRICS. 

Its  weight  at  birth  was  3400  grammes  (7^  pounds).  At  ten  days  it  weighed  3200 
grammes  (7  pounds.)  It  was  perfectly  healthy  at  birth,  and  its  skin  was  of  the  usual 
pink  color  which  is  seen  in  healthy  new-born  infants.  On  the  fourth  day  of  its  life 
the  skin  began  to  show  a  yellow  color,  which  soon  became  intensified,  representing 
very  well  the  picture  of  a  physiological  icterus  neonatorum.  The  yellowish-brown 
color  of  the  abdomen,  and  the  slightly  icteric  color  of  the  conjunctivas  are  to  be  noticed 
especially.  The  urine  in  this  case  Avas  apparently  normal,  and  the  faecal  discharges 
were  tinged  with  the  dark  color  of  the  meconium.  In  a  week  this  yellow  color  will 
usually  .almost  entirely  disappear,  and  the  skin  will  assume  the  natural  pink  color  of 
a  healthy  infant  in  the  first  month  of  life.  Later  it  will  become  whiter  and  more  like 
the  skin  of  the  the  older  child. 

Infants  affected  with  a  severe  form  of  icterus  neanatorum  show  a 
strong  tendency  to  a  physiological  loss  of  weight  which  is  greater  than 
normal,  and  it  may  be  three  or  even  four- weeks  before  the  child  begins  to 
gain  in  weight.  We  have  had  a  case  in  which  for  two  weeks  there  was  a 
steady  loss,  amounting  to  ,130  before  the  gain  in  weight  began.  In  another 
case  the  jaundice  continued  for  six  weeks  with  a  gain  of  only  three  ounces. 
It  is  interesting  to  note  that  the  latter  case  was  breast  fed  and  had  been 
given  nearly  a  grain  of  calomel  daily  for  four  weeks  by  the  physician 
without  influencing  in  the  least  the  color  of  the  skin  or  of  the  movements. 
Although  the  majority  of  cases  of  icterus  neanatorum  are  of  a  mild  and 
transitory  nature,  it  is  well  to  bear  in  mind,  when  giving  a  prognosis,  that 
some  occur  in  which  the  intensity  of  the  jaundice,  the  loss  of  weight,  and 
long  duration  lead  to  a  strong  suspicion  of  the  existence  of  some  con- 
genital malformation  of  the  bile-ducts. 

As  to  the  cause  of  icterus  noenatorum,  the  investigations  of  Birch- 
Hirschfeld  seem  to  be  the  most  thorough  and  to  offer  the  most  rational 
explanation.  This  author  says  that  it  is  difficult  to  avoid  associating  the 
icterus  in  some  way  with  a  disturbance  of  the  hepatic  circulation,  owing 
to  the  transfer  of  its  chief  blood  supply  from  the  umbilical  vein.  This  is 
especiahy  to  be  seen  when  we  consider  the  very  evident  congestion  and 
oedema  of  the  liver  which  occur  in  cases  in  which  the  circulation  through 
the  umbilical  cord  is  interrupted  before  the  respiratory  movements,  by 
their  effect  on  the  right  side  of  the  heart,  afford  an  adecpiate  compensation. 

This  explanation  of  the  cause  of  icterus  noenatorum  must  not,  how- 
ever, be  regarded  as  conclusive  ;  for  Cohnheim  has  in  a  number  of  autop- 
sies made  on  this  class  of  cases  failed  to  substantiate  the  conditions  de- 
scribed by  Birch-Hirschfeld. 

Treatment. — The  ordinary  bathing  of  the  infant's  skin  is  all  that  is 
necessary  in  these  cases  of  icterus  neonatorium,  and  we  have  never  seen 
any  indication  for  especial  treatment  of  this  condition  beyond  great  care  in 
establishing  the  equilibrium  between  the  food  and  the  digestion.  Great 
harm  may  be  done  by  the  continued  use  of  calomel  in  these  cases.  Its 
use  is  of  very  doubtful  value. 

Erythema  Neonatorum. — At  birth  the  skin  is  exceedingly  sensitive 
to  external  influences,  and  in  every  case  shows  variations  in  color  according 


DISEASES   OF  THE  NEW-BORN,  311 

to  the  degree  of  this  sensitiveness,  and  to  the  greater  or  less  amount  of 
irritation,  whether  from  temperature  or  from  mechanical  causes,  to  which 
it  is  exposed. 

The  delicate  layers  of  epithelium  are  commonly  thrown  off  to  such  a 
degree  as  almost  to  represent  a  physiological  desquamation,  and  it  is  often 
several  weeks  before  the  normal  infantile  condition  of  the  skin  is  reached. 
In  c|uite  a  number  of  cases  this  natural  condition  becomes  intensified,  and 
we  find  a  uniform  redness  of  the  whole  skin,  which  usually  appears  in 
the  first  two  or  three  days  of  life.  In  a  considerable  number  this  hyper- 
semic  condition  of  the  skin  gradually  fades  away  in  about  a  week,  and  is 
replaced  by  a  normal  pink  color.  In  many  other  cases,  however,  the  red 
color  may  be  com.plicated  by  an  interic  condition,  or  it  may  change  with 
many  intermediate  shades  of  red  and  yellow  mto  a  pronounced  icterus 
neonatorum.  Plate  II.,  facing  page  75,  represents  a  typical  case  of  an 
uncomplicated  erythema  neonatorum. 

The  infant,  a  female,  weighed  at  birth  3000  grammes  (6J  pounds).  It  began  to 
turn  red  when  it  was  twenty  hours  old,  and  four  hours  later  was  of  a  dull  but  pro- 
nounced red  color  all  over  its  face,  head,  thorax,  and  extremities.  Its  temperature 
and  respirations  were  normal,  and  it  seemed  perfectly  well. 

Symptoms. — There  are  usually  no  constitutional  symptoms  in  these 
cases.  When  the  hyperaemia  is  ve-ry  intense  a  slight  desquamation  is  at 
times  noticed.  It  is  well,  therefore,  to  study  this  rather  peculiar  red 
tinge  of  the  skin  in  comparison  Avith  the  redness  of  simple  erythema,  ec- 
zema, erysipelas,  and  scarlet  fever,  which,  owing  to  the  different  degree 
of  sensitiveness  of  the  individual  skin,  may  at  times  simulate  erythema 
neonatorum  as  well  as  each  other.  The  possibility  of  this  error  must  be 
accepted,  since  these  other  diseases  have  been  known  to  appear  as  early 
in  life  as  in  the  above  case,  although  it  is  unusual  for  them  to  do  so.  In 
one  instance,  at  least,  to  my  knowledge,  a  case  of  scarlet  fever,  which 
ultimately  proved  fatal  to  another  child  in  the  family,  was  considered  by 
the  attending  physician,  when  he  first  saw  it,  to  be  a  case  of  erythema 
neonatorum  in  the  second  week  of  life,  and  yet  eventually  he  admitted  it 
to  be  the  source  of  infection  of  the  other  members  of  the  family  and  of 
the  death  of  one  of  them. 

Treatment. — The  application  of  a  simple  powder,  such  as  is  given 
below,  with  the  use  of  water  without  soap  on  the  skin,  using  enough 
only  for  cleanliness,  until  the  redness  had  disappeared,  is  generally  all  the 
treatment  that  is  necessary  in  these  cases. 

Prescription  12. 
Metric.  Apothecary. 


Gramma. 


R     Pulv.  zinci  oxidi 30 

Pulv.  amyli  trit 120 


B     Pulv.  zinci  oxidi 5  i ; 

Pulv.  amyli  trit ^  iv. 


M.  '  M. 


312 


PEDIATRICS. 


Naevus. — There  are  two  forms  of  pathological  disturbance  in  connec- 
tion with  the  blood-vessels  of  the  skin  which,  appearing  at  birth,  consti- 
tute a  disease  called  naevus.  Both  these  forms  can  appear  on  the  skin  of 
any  part  of  the  infant,  but  its  occurrence  is  especially  unfortunate  when 
it  is  located  on  the  face. 

The  first  form  is  very  superficial  in  its  distribution,  and  is  the  one 
which  is  usually  called  "  port-wine  mark."  This  form  can  in  a  number 
of  cases  be  destroyed  by  the  use  of  electricity.  The  second  form,  which 
is  deep  in  its  distribution,  as  a  rule  needs  to  be  treated  by  the  knife  or  by 
the  Paquelin  cautery.  Cases  of  the  superficial  form  of  naevus  are  quite 
common  and  vary  greatly  in  degree.     A  frequent  locality  is  between  the 

Fig.  78. 


Naevus  of  face  and  neck  in  an  infant  4  montlis  old. 


eyes  at  the  bridge  of  the  nose,  and  another  is  on  one  of  the  eyelids.  Often 
in  these  cases  the  disturbance  diappears  of  itself  after  a  few  weeks  or 
months  and  does  not  return.  In  other  cases  the  lesion  remains,  often  in- 
creases and  continues,  unless  treated,  through  life.  In  the  second  form 
much  can  be  done  by  operative  interference.  This  form  also  varies 
greatly  in  size  and  in  the  degree  of  the  telangiectasis.  In  operating  on 
these  cases  it  should  be  remembered  that  at  times  the  hemorrhage  is 
great,  and  that  the  infants  are  liable  to  die  from  exhaustion. 


DIVISION    VI. 

DISEASES   OF   NUTRITION. 


There  are  four  diseases  which  so  essentially  belong  to  the  early  years 
of  life,  and  so  far  as  our  knowledge  of  them  goes  are  so  obscure  in  their 
etiology,  while  presenting  each  in  its  o^^n  peculiar  manifestations  a  clear 
picture  of  a  vice  of  nutrition,  that  for  the  present  we  must  classify  them  by 
themselves  as  dieases  of  nutrition.  These  diseases  are  I'hachitis,  osteoma- 
lacia^ infantile  scorbutus,  and  infantile  atrophy.  Of  these,  rhachitis  and 
infantile  atrophy  are  diseases  of  the  first  two  years  of  life.  Infantile  scor- 
butus, while  having  its  counterpart  in  the  scorbutus  of  a  later  period, 
especially  in  its  pathology  and  treatment,  shows  in  its  symptoms  and 
course  such  a  characteristic  picture  in  the  middle  period  of  infancy  that  it 
may  be  considered  at  least  as  forming  a  special  form  of  scorbutus. 

RHACHITIS  (Rickets). 

Rhachitis  is  a  disease  closely  connected  with  impaired  nutrition.  It 
occurs  usually  in  infancy,  rarely  in  early  cliildhood,  and  appears  at  a  time 
when  the  bones  are  in  the  process  of  development.  It  is  chronic  in  its 
course,  and  although  its  chief  lesions  are  in  the  bones,  it  involves  all  the 
tissues  and  organs  of  the  body.  Its  chief  characteristic  is  a  local  or  gen- 
eral disturbance  of  the  normal  process  of  ossification,  but  exactly  how  the 
dietetic  and  hygienic  causes  which  are  supposed  to  produce  these  osseous 
changes  accomplish  their  results  is  still  unknown.  The  uniform  and  defi- 
nite changes  in  the  bones  in  rhachitis  lead  us  to  consider  it  a  disease  of 
itself  and  one  which,  although  connected  with  nutrition,  is  not  merely  a 
fonn  of  malnutrition. 

Etiology  a\d  Occurrence. — -There  is  no  evidence  that  rhachitis  is 
hereditary.  Although  the  disease  seldom  begins  before  the  sixth  month 
or  later  than  the  third  year,  there  is  no  doubt  that  it  is  met  with  at  both 
an  earlier  and  a  later  period,  and  cases  have  been  reported  in  which  the 
rhachitic  rosar}^  was  seen  as  early  as  the  fourth  week  after  birth.  The 
tendency  of  the  disease  to  occur  m  the  first  two  years  of  life  is  shown  in 
the  following  collection  of  1876  cases  compiled  by  Guerin,  Brunische, 
Rittershain,  Ritsche,  and  Baginsky. 

313 


314  PEDIATRICS. 

Cases.  Per  Cent. 

First  year 710  37.8 

Second  vear 831  44.3 

Third  year 232  12.4 

Fourth  year 50  2.7 

Fifth  year 27  1.4 

Over  five  years 26  1-4 

1876  100.0 

There  does  not  seem  to  be  any  marked  difference  in  the  frequency 
with  which  boys  and  girls  are  affected  by  rhachitis.  Out  of  2595  cases 
reported  by  various  authors,  there  were  1337  boys  and  1258  girls. 

Such  authors  as  Ziegler  and  Vierordt  consider  that  foetal  rhachitis  is 
doubtful,  but  whatever  the  pathological  point  of  view  may  be,  a  condition 
closely  simulating  rhachitis  from  a  clinical  stand-point  exists  occasion- 
ally durmg  foetal  life.  At  about  the  age  of  puberty  also,  m  certain  in- 
dividuals, the  physical  signs  of  rhachitis,  with  the  exception  of  a  lesser 
degree  of  epiphyseal  enlargement,  occur,  and  m  these  cases  albuminuria  is 
usually  present.  These  cases  are  called  the  rhachitis  of  adolescence  or 
late  rhachitis.  Certain  races,  such  as  the  lower  classes  in  Italy  and  Eng- 
land, are  notably  affected  by  rhachitis.  The  disease,  on  the  contrary,  in 
a  marked  form  is  not  common  among  native-born  Americans,  nor  is  it 
as  a  rule,  of  so  severe  a  type  m  America  as  m  England ;  and,  except  in 
colored  children,  or  in  Italians  and  Portuguese,  great  deformities  are  rare 
in  America.  Greeks  and  Gypsies  seem  to  be  almost  exempt.  The  prev- 
alence of  rhachitis  among  the  colored  population  in  Northern  cities  is  most 
strikmg,  and  the  disease  is  not  so  common  among  the  negro  population 
in  the  Southern  States.  The  great  predisposition  to  rhachitis  which  has 
been  shown  by  the  people  in  Southern  Europe  has  never  been  accounted 
for.  The  most  severe  cases  occur  in  cold,  moist  clmiates  ;  it  is  rare  in 
sub-tropical,  almost  alDsent  in  tropical,  regions,  and  almost  unknown  in  the 
Arctic  regions.  It  is  seldom  met  with  in  Chma,  Japan,  Turkey,  and  the 
southern  portions  of  Italy  and  Spain  (Palm).  Even  in  the  regions  where 
it  is  prevalent  it  is  not  common  in  the  high  altitudes.  It  is  probable  that 
a  great  number  of  cases  occur  very  early  in  life,  but  are  so  mild  in  form 
that  the  rhachitic  lesions  do  not  become  sufliciently  marked  for  recog- 
nition until  later.  It  is  certainly  much  more  common  in  its  occurrence 
among  all  classes  of  Iffe  than  was  formerly  supposed,  and  this  is  especially 
true  of  the  population  of  large  cities  and  towns. 

Out  of  400  cases  examined  at  the  Infant's  Hospital  in  a  children's 
out-patient  clinic  by  Morse,  80  per  cent,  showed  distinct  changes  in  the 
bones  characteristic  of  rhachitis.  This  percentage  is,  however,  undoubt- 
edly too  low,  as  besides  the  fact  that  large  numbers  of  cases  of  rhachitis 
do  not  present  marked  deformities  of  the  head  or  extremities,  and  are, 
therefore,  not  always  recognized,  it  was  the  case  also  that  many  infants 
only  a  few  days  old  were  included  in  the  400,  and  only  those  cases  were 
called  rhachitic  in  which  changes  in  the  bones  were  evident. 


DISEASES   OF  NUTRITION.  315 

As  a  congenital  disease  it  is  probably  associated  with  lack  of  proper 
intra-uterine  development,  corresponding  to  the  rhachitis  which  is  met 
with  in  cases  of  prolonged  lactation.  Like  all  diseases  associated  with 
impairment  of  nutrition,  it  is  less  likely  to  occur  among  breast-fed  infants 
than  among  those  who  are  deprived  of  their  natural  food,  but  if  the  breast- 
milk  is  deficient  in  fat  and  proteids  the  disease  may  develop.  The 
frequent  occurrence  of  rhachitis  in  breast-fed  babies  is  a  strong  argument 
against  the  opinion  held  by  some  writers  that  sterilization  of  milk  is  a 
direct  and  important  cause  of  the  disease.  It  has  been  noted  in  New 
York  (Holt)  that  among  the  Italians  it  is  very  common  to  see  marked 
rhachitis  in  infants  who  are  getting  no  food  but  that  from  the  breast. 
In  like  manner  it  is  more  likely  to  develop  in  the  latter  part  of  the 
first  year  than  in  the  earlier  months,  since  in  so  many  cases  the  breast- 
milk  deteriorates  in  quality  after  the  first  six  or  seven  months  of  lacta- 
tion. The  disease  also  seems  to  occur  when  the  food  is  not  properly 
adapted  to  the  especial  age,  and  the  later  children  of  large  families  are 
more  apt  to  contract  the  disease  than  the  earlier  ones.  According  to  the 
investigations  of  Konig,  Forster,  Gomp,  and  Besanez,  it  was  found  that 
there  was  not  a  deficiency  of  lime  in  the  food  taken  by  rhachitic  children. 
It  is  most  probable,  how^ever,  that  rhachitis  is  closely  connected  with  some- 
thing which  interferes  with  the  assimilation  of  the  lime-salts.  In  regard 
to  the  especial  elements  of  the  food  which  hold  a  prominent  place  in  the 
production  of  the  disease,  it  seems  as  though  a  low  percentage  of  fat,  es- 
pecially when  combined  with  a  low  percentage  of  proteids,  was  conducive 
to  the  production  of  rhachitis.  It  is  therefore  very  evident  how  the  pro- 
prietary foods  become  a  prominent  factor  in  the  production  of  the  disease, 
for  all  of  them  contain  a  notably  small  amount  of  fat.  Babies  fed  on 
excessive  diets  may  develop  rhachitis.  Pritchard  believes  that  an  over- 
supply  of  carbohydrates  is  especially  liable  to  be  a  cause.  Other  writers 
have  attempted  to  associate  rhachitis  with  a  diminished  secretion  of  the 
thymus  gland,  but  proof  of  this  theory  is  wanting.  Next  to  the  food,  the 
general  hygiene  is  of  the  greatest  importance,  and  the  disease  is  especially 
noticeable  in  the  crowded  tenement  districts  of  large  cities.  The  actual 
cause  and  nature  of  rhachitis  is  unknown. 

Rhachitis  is  a  general  disease,  and  there  seems  to  be  some  change  in 
the  metabolism,  possibly  from  the  circulation  of  some  substance,  in  conse- 
quence of  which  there  are  local  changes  in  the  metabolism  with  a  lessened 
deposition  of  lime  combined  with  a  certain  amount  of  resorption  of  bone. 
Whatever  the  other  causes  of  rhachitis  may  be,  it  is  evident  that  inter- 
ference with  nutrition  by  improper  food  and  lack  of  suitable  hygienic 
surroundings  play  a  prominent  role  in  its  production. 

An  infectious  cause  for  the  disease,  though  still  to  be  considered,  has  as 
yet  in  no  way  been  proved.  The  same  may  be  said  of  the  theory  of 
intestinal  autointoxication.  The  theories  of  a  lack  of  lime  in  the  circula- 
tion, or  the  circulation  of  an  acid,  or  a  diminished  alkalinity  of  the  blood 


316 


PEDIATRICS. 


can  be  eliminated  as  causes.  The  growth  of  cartilage  and  of  osteoid  tissue 
may  be  the  result  of  lack  of  lime,  or  may  perhaps  be  primarily  produced 
and  may  be  an  agent  of  bone  change,  but  there  is  no  proof  of  this.  The 
vascular  inflammatory  theory  of  Kassowitz  is  not  probable,  and  Oppen- 
heimer's  theory  of  malaria  is  without  foundation. 

In  addition  to  the  causes  of  rhachitis,  in  which  the  etiology  is  some- 
what obscure,  many  cases  occur  which  evidently  are  secondary  to  and 
result  from  a  number  of  diseases  wliich  effect  the  general  nutrition  of 
the  infant.  Thus,  diseases  of  the  gastro-enteric  tract,  when  they  are  pro- 
longed for  some  time,  lead  to  the  condition  of  rhachitis.  We  also  meet 
with  it  in  cases  of  syphilis  in  which  the  nutrition  is  much  reduced  ;  but 
beyond  this  relation  between  syphilis  and  rhachitis, — namely,  that  rhachitis 
is  secondary  to  syphilis,  as  it  might  be  to  any  wasting  disease,  the  two 
diseases  are  essentially  distinct.  It  is  to  be  noted  in  this  connection  that 
cases  of  infantile  atrophy,  no  matter  how  much  they  are  wasted,  do  not 
present  the  lesions  of  rhachitis,  although  in  some  cases  Ave  find  the  two 
conditions  associated.  We  must  also  remember  that  the  nutrition  of  all 
the  tissues  is  profoundly  affected,  and  that  the  equilibrium  of  the  nervous 
system  in  rhachitis  is  very  unstable. 

Pathological  Anatomy. — Bone  Lesions. — The  pathological  lesions  of 
•rhachitis  are  represented  chiefly  in  the  bones,  and  occur  during  the  period 


Fig.  79. 


I. 


II. 


III. 


-z.  p. 


-     ■    -z.  p. 


I.  Normal  bone :  Z.  P.,  zone  of  proliferation.    11.  Bone  of  a  cretin :  Z.  P.,  zone  of  proliferation. 
III.  Rhacliitic  bone  :  Z.  P.,  zone  of  proliferation. 

in  which  the  normal  processes  of  ossification  are  most  active, — that  is, 
during  the  first  year  and  the  first  part  of  the  second  year  of  life. 

The  normal  growth  of  bone  depends  upon  four  conditions :  (a)  multi- 
plication of  cartilaginous  cells  in  definite  lines,  followed  by  (6)  calcifica- 


DISEASES    OF   XUTRITION.  317 

tion  of  the  intercellular  spaces ;  (c)  the  formation  of  medullary  spaces  by 
the  penetration  of  the  blood-vessels,  with  subsequent  absorption  of  tissue  ; 
and  (d)  finally,  the  concentric  deposition  of  bone  within  the  medullary 
spaces.  The  bones  grow  in  length  by  the  production  of  bone-tissue  in 
the  cartilage  between  the  epiphysis  and  the  diaphysis,  and  in  thickness  by 
the  growth  of  bone  from  the  inner  layers  of  the  periosteum.  At  the 
same  time  the  medullary  canal  is  enlarged  in  proportion  to  the  growth  of 
the  bone  by  the  absorption  of  its  inner  layer.  These  processes  progress 
in  definite  order  and  in  clearly  defined  zones. 

In  rhachitis  the  chief  microscopic  features  are  the  changes  which  occur 
in  the  zones  of  growth  and  the  asymmetrical  character  of  the  proliferative 
processes.  The  cartilaginous  and  sub-periosteal  cell-growth  which  pro- 
duces ossification  goes  on  with  increased  rapidity  and  in  an  irregular 
manner  both  between  the  epiphysis  and  the  diaphysis  and  beneath  the 
periosteum.  If  we  examine  microscopically  the  region  between  the  epiph- 
ysis and  the  diaphysis,  usually  called  the  zone  of  proliferation,  we  find 
that  the  cartilagmous  cells  are  not  regularly  arranged  in  rows  around  a 
definite  zone  in  advance  of  the  rmg  of  ossification,  as  in  normal  tissue, 
but  that  there  is  an  iiTegular  heaping  up  of  cartilaginous  cells,  sometimes 
in  rows,  sometimes  not,  covering  an  ill-defined  irregular  area.  This  zone 
of  proliferation  also,  instead  of  being  narrow  and  sharply  defined,  is  quite 
lacking  in  unifonnity.  It  presents  a  broad,  reddish-gray  appearance,  with 
marked  thickening  and  hj'pergemia.  The  medullary  spaces  are  much 
more  vascular  than  normal,  and  are  so  increased  m  area  as  to  extend 
into  the  zone  of  calcification,  and  sometmies  through  it.  The  deposit 
of  bone-tissue  within  these  spaces  is,  however,  either  alDsent  or  very 
irregular,  and  is  for  the  most  part  replaced  by  a  soft,  frialDle  suJDstance, 
consisting  of  a  bone-tissue  that  is  very  lacking  in  Imie-salts,  with  cells  of 
various  kinds  emlDedded  in  a  fibrillated  ground-sulDstance.  This  tissue  is 
called  "osteoid,"  and  is  similar  to  that  formed  by  osteoblasts. 

In  the  region  of  ossification  (ends  of  diaphysis  and  epiphysis)  there 
is  microscopically  a  pronoimced  increase  of  blood-vessels  and  cartilage- 
cells,  with  lengthening  of  cell  columns,  and  disturbance  of  calcification 
of  the  intercellular  substance.  Calcification,  if  present,  may  be  isolated 
in  the  region  of  the  proliferating  cartilaginous  cells,  or  may  be  altogether 
absent  over  considerable  areas.  The  siil3-periosteal  layer  of  cells  which 
is  normally  thin  and  scarcely  noticeable  macroscopically,  becomes  hyper- 
semic  and  thickened  with  an  appearance  similar  to  that  of  spleen-pulp. 
Beneath  this  periosteum  is  also  to  be  found  the  "  osteoid"  tissue  seen  in 
the  zones  of  proliferation. 

The  medulla  of  the  bone  is  more  hypersemic  even  than  normal.  Its 
tissue  is  rich  in  cells,  and,  like  the  foetal  medulla,  contains  dilated  vessels 
and  fat.  The  intercellular  sulDstance  may  show  mucoid  degeneration  or 
even  be  of  fluid  consistency.  In  such  a  condition  it  does  not  seem  that 
Jime  is  dissolved  from  the  bone  tissue  by  the  blood,  but  it  is  the  resorp- 


318 


PEDIATRICS. 


Fig.  80. 


tion  of  such  bone  in  toto  that  is  the  important  factor  in  the  process. 
Resorption  at  the  age  at  which  rhachitis  occurs  is  normal.  Pimmes, 
especially,  believes  that  resorption  in  rhachitis  is  not  increased.  Muller 
and  Virchow  seem  to  hold  the  same  views,  while  Kassowitz  and  Ziegler 
think  it  is  increased.  Clinically,  certain  extremely  rapid  cases  of  softening 
seem  to  show  increased  resorption  (Vierordt).  Ordinarily,  with  a  resorp- 
tion not  greatly  increased,  the  formation  of  fresh  bone  containing  but 
little  lime  results  in  loss  of  strength.  In  the  skull,  in  some  places,  ab- 
sorption predominates  (occiput) ;  in  other  cases  accretion  of  osteoid  tissues 
(frontal  and  parietal  eminences).  Deficient  bone-growth  simply  deter- 
mines open  fontanelles.  In  convalescence  lime  is  deposited  in  the  previous 
Imieless  osteoid  tissue,  and  the  result  is  a  thick  and  heavy  bone.  In  frac- 
tures at  this  period  callus-formation  is  intense  and  excessive. 

An  excessive  proliferation  of  cells  in  the  inner 
layers  of  the  periosteum,  the  irregular  calcifica- 
tion which  occurs  about  them,  and  the  absence  of 
uniformity  in  the  elaboration  of  the  structure  of 
the  bone,  produce  an  irregular,  spongy  bone-tissue 
instead  of  the  compact  lamellated  tissue  which  is 
so  necessary  for  the  uniformity  of  the  structure. 
The  increased  cell-growth  between  the  epiphysis 
and  the  diaphysis  produces  the  peculiar  knobby 
swellings  which  are  characteristic  of  rhachitis. 
At  the  same  time  the  medullary  cavity  increases 
rapidly  in  size,  and  the  inner  layers  of  the  bone 
become  spongy.  The  result  of  these  processes  is 
to  diminish  the  solidity  of  the  bones  so  that  they 
cannot  resist  the  strain  of  the  muscles  or  outside 
pressure.  After  a  time  the  rhachitic  process  may 
stop  and  the  bones  may  assume  a  more  normal 
character.  The  porous  bone-tissue  becomes  com- 
~pact,  and  even  unnaturally  dense,  so  that  in  later 
childhood  the  rhachitic  bone  is  unusually  hard, 
like  ivory,  a  condition  noticed  by  those  who  have 
to  operate  on  these  bones. 

Fig.  79,  I.,  represents  a  section  of  a  normal 
bone  taken  from  an  infant,  and  shows  the  normal 
zone  of  proliferation  (Z.  P.)  between  the  epiphysis 
and  the  diaphysis. 

Fig.  79,  III.,  represents  a  section  of  a  rhachitic 
bone,  and  shows  the  broad,  irregular,  and  abnor- 
mal zone  of  proliferation  (Z.  P.)  just  described. 

Fig.  80  represents  a  section  of  a  rhachitic  bone, 
ihustrating  the  great  enlargement  of  cartilage  at  the  epiphysis,  with  the 
irregular  foci  of  calcification.     The  diaphysis  of  the  bone  shows  perios- 


Spindle-shaped  rhachitic 
bone. 


DISEASES   OF   ^XTRITION.  319 

teal  thickening  to  such  an  extent  that  it  encroaches  on  the  medullary 
cavity,  which  is  much  diminished.  It  is  possible  that  this  bone  represents 
a  very  rare  condition  of  periosteal  dysplasia,  described  by  Schuchardt, 
which  is  characterized  by  growth  in  height  and  not  in  breadth. 

Visceral  Lesions ;  Spleen.  —  The  investigations  made  by  Sasuchin 
(Jahrb.  fiir  Kinderhl.,  March  13,  1900)  have  shown  that  in  cases  of  rha- 
chitis  which  come  to  autopsy  the  spleen  is  invariably  enlarged,  Avith  the 
exception  of  the  cases  of  clearly  pronounced  general  atrophy,  in  which 
the  spleen  is  of  normal  size  and  weight  or  below  normal.  A  second 
marked  characteristic  is  the  more  or  less  significant  thickening  of  the 
capsule  and  the  increase  in  the  consistency  of  the  organ.  The  third 
peculiarity  of  the  rhachitic  spleen  is  the  anaemia  of  the  organ  and  the 
dimmution  in  the  nmiiber  of  Malpighian  bodies,  which  in  children  are 
otherwise  well  developed,  but  in  these  conditions  are  smooth  and  hardly 
perceptible.  On  section,  the  spleen  has  a  blood-red  color,  the  trabeculse 
are  clearly  marked  by  interlacing  threads,  and  on  draA\ang  the  knife  over 
the  cut  surface  there  remains  upon  the  edge  blood  and  pulp-tissue.  The 
characteristics  described  hold  true  in  all  cases  of  rhachitis,  and,  in  gen- 
eral, indicate  approximately  the  intensity  of  the  changes  in  the  bones. 

The  microscopic  appearances  are  those  of  an  interstitial  splenitis. 
Whether  the  mflammator}''  appearances  are  directly  dependent  upon  the 
rhachitis  or  are  due  to  the  complicating  diseases  which  caused  the  death 
of  the  patient  has  not  been  definitely  determined.  The  uniform  appear- 
ances in  all  the  cases  exammed  by  Sasuchin,  irrespective  of  the  cause  of 
death,  seem  to  give  weight  to  the  opinion  that  the  lesions  are  directly 
connected  with  the  rhachitis. 

Symptoms. — Constitutional. — The  symptoms  of  rhachitis  are  those  of 
a  slowly  developing  constitutional  disease.  The  early  symptoms  are  the 
same  as  may  occur  in  a  number  of  diseases  in  which  the  nutrition  is 
affected.  The  most  common  early  symptoms  are  restlessness  at  night, 
profuse  sweatmg,  especially  of  the  head,  when  asleep,  and  constipation 
alternating  at  times  with  diarrhoea.  The  appetite  is  unpaired  and  ca- 
pricious ;  the  infants  are  fretful,  the  abdomen  becomes  prominent,  and 
although  they  often  grow  fat  they  are  aneemic  and  their  muscles  are  soft. 
The  increase  m  weight  depends  mostly  on  an  increase  in  fat,  the  normal 
relative  proportion  between  fat  and  muscle  being  altered.  The  infants  do 
not  learn  to  walk  as  early  as  they  should ;  their  fontanelles  do  not  close 
at  the  usual  time ;  dentition  is  delayed  and  irregular,  and  soft  areas  ap- 
pear in  the  cranial  bones,  especially  in  the  occiput. 

At  this  stage  the  characteristic  tenderness  of  the  body  may  occur, 
but  many  cases  never  present  this  symptom.  This  is  usually  due  to  a 
periosteal  tenderness  at  the  insertions  of  the  muscles,  and  is  sometimes 
confined  to  the  bones.  It  is  manifested  only  on  trifling  pressure,  while 
at  other  times  the  muscles  are  tender  and  the  gentlest  effort  to  lift  the 
child  may  cause  him  to  shriek  with  pain.  It  must,  however,  be  remem- 
bered that  pain  in  rhachitis  may  be  connected  with  an  early  manifestation 


320  PEDIATRICS. 

of  scorbutus,  which  is  not  an  uncommon  compHcation  of  rhachitis.  The 
so-called  paralysis  of  rhachitis,  which  is  an  accompaniment  of  this  stage, 
and,  as  a  rule,  precedes  any  marked  osseous  change,  is  generally  brought 
to  notice  by  the  child's  inability  or  disinclination  to  walk  or  to  stand.  At 
other  times  it  may  be  more  severe  and  take  the  form  of  inability  to  use  the 
arms  as  well  as  the  legs.  There  may  be  a  slight  and  irregular  heightening 
of  the  temperature  apart  from  any  complications  which  can  be  detected. 

Convulsions  may  occur,  especially  when  there  is  a  tendency  to  cranio- 
tabes.  In  certain  cases  these  symptoms  are  all  so  acute  that  some  writers 
would  make  them  a  separate  class  under  the  head  of  acute  rhachitis,  but 
the  anatomical  lesions  and  the  symptoms  are  the  same,  except  for  their 
greater  severity,  and  would  seem  to  belong  clearly  enough  to  the  same 
group  as  the  less  pronounced  cases.  There  has  also  been  much  dis- 
cussion as  to  whether  a  form  of  acute  rhachitis  exists  apart  from  the  dis- 
ease scorbutus.  But  cases  presenting  the  symptoms  to  be  described  under 
the  heading  of  scorbutus  should  not  be  considered  necessarily  as  acute 
forms  of  rhachitis  on  account  of  the  severity  of  the  symptoms,  but  should 
be  classed  as  scorbutus  supervening  on  rhachitis.  The  later  and  more 
characteristic  symptoms  of  the  disease  soon  appear  and  are  represented 
chiefly  in  the  osseous  system.     The  facial  expression  is  usually  intelligent. 

After  these  general  premonitory  symptoms  have  continued  for  some 
time  the  characteristic  changes  in  the  osseous  system  become  prominent 
and  are  found  in  those  parts  of  the  bones  which  are  in  the  most  active 
stage  of  development.  In  the  early  days  of  extra-uterine  life  the  skull 
undergoes  the  most  marked  changes. 

Head. — The  typical  head  of  rhachitis  has  a  high,  square,  prow- 
shaped  forehead,  with  a  decided  prominence  of  the  lateral  parts  of  the 
frontal  bones  (frontal  eminences),  and  sometimes  there  are  also  eminences 
on  the  parietal  bones.  (Fig.  84,  page  325.)  The  normal  thickness  of  the 
bones  is  increased  by  means  of  a  large  amount  of  new  periosteal  soft 
growth  between  the  periosteum  and  the  bones.  The  head  is  somewhat 
lengthened  beyond  the  normal  shape,  and  is  usually  larger  in  circumfer- 
ence than  normal.  The  anterior  fontanelle  remains  widely  open,  and  may 
not  ossify  until  the  third  year,  or  even  later.  The  closure  of  the  posterior 
fontanelle  may  be  delayed  in  cases  which  develop  rhachitis  very  early  in 
life.  The  sutures  also  remain  open  longer  than  normal,  and  in  such  cases 
may  result  in  leaving  a  depression  in  the  course  of  the  sagittal  suture. 
Sometimes,  however,  a  prominence  is  found  instead  of  a  depression. 

The  square,  lengthened,  rhachitic  head  is  shown  in  Fig.  84,  page  325, 
and  in  Fig.  85,  opposite  page  328.  Flattening  of  the  back  and  top  of 
the  head  and  asymmetry  of  the  head  may  result  from  softening  of  the 
bones.  The  normal  shape  is  usually  regained  when  the  disease  is  cured. 
The  bones  may  be  soft,  porous,  and  hyperaemic,  while  at  their  edges 
there  may  be  rough  bony  projections  beneath  the  periosteum. 

The  name  craniotabes  is  applied  to  an  abnormal  thinness  of  portions  of 


DISEASES   OF  NUTRITION.  321 

the  parietal  and  occipital  bones,  which  are  filled  only  with  a  fibrous  mem- 
brane, and  which  yield  to  gentle  pressure  and  give  a  sensation  of  crack- 
ling parchment.  Hypergemia  of  the  brain  and  meninges,  of  course,  may 
be  an  accompaniment  of  any  affection  of  the  skull  so  severe  as  this.  With 
this  hyperaemia  comes  the  likelihood  of  hydrocephalus,  either  external  or 
internal,  and  the  accompanying  cerebral  changes,  so  that  hydrocephalus 
becomes  a  complication  which  is  not  very  rare.  This  condition  of  the 
bone  may  be  only  temporary,  and  the  areas  of  thickening  are  often  ab- 
sorbed ;  but  if  there  is  much  deposit  under  the  periosteum  it  will  some- 
times remam,  and  where  calcification  takes  place  quickly  the  thickened 
areas  of  the  bone  will  remain  unabsorbed  throughout  life.  At  times  the 
jaw-bones  are  affected :  the  upper  jaw  is  then  found  to  spread  behind, 
and  to  be  pomted  in  front,  while  the  lower  jaw  is  flat  in  front  and  bent  in 
at  the  sides,  making  an  angle  at  the  site  of  the  canine  teeth. 

Thorax. — The  rhachitic  thorax  is  narrow  and  is  compressed  laterally, 
— that  is,  there  is  a  tendency  to  a  flattening  of  the  sides  of  the  chest  and 
to  an  increase  of  the  antero-posterior  diameter.  The  forces  which  pro- 
duce deformities  of  the  thorax  are  dependent  on  the  muscular  action  on 
the  soft  bones  by  pulling,  atmospheric  pressure  from  without,  and  the 
pressure  exerted  on  the  bony  structures  by  growing  organs. 

A  transverse  depression  may  also  occur,  starting  at  the  junction  of  the 
ensiform  cartilage  to  the  sternum,  extending  laterally  on  the  thorax,  and 
corresponding  to  the  msertion  of  the  diaphragm.  This  is  called  Harri- 
son's groove.  The  diaphragm,  by  its  strong  muscular  action  along  the 
line  of  its  insertion,  may  also  cause  a  furrow  in  the  lower  part  of  the 
chest.  The  lower  ribs  may  also  be  elevated  by  the  underlymg  distention 
caused  by  the  prominent  abdomen  and  the  liver,  which  is  always,  even 
in  normal  cases,  large  in  proportion  to  the  other  organs.  Softening  of 
the  ribs  is  said  to  occur  (Vierordt)  after  the  changes  in  the  skull  and 
before  the  changes  in  the  extremities.  In  a  typical  rhachitic  thorax  the 
clavicles  are  shorter  and  more  curved  than  normal,  and  the  clavicular 
deformities  may  be  unilateral,  as  seen  in  Fig.  85,  I.  and  II.,  facing  page 
328.  Fractures  of  the  clavicles  in  rhachitis  are  not  uncommon  on  the 
forward  curve,  and  may  possibly  occur  when  the  infant  is  being  dressed. 

When  there  is  unusual  lateral  compression  and  narrowing  of  the 
thorax,  the  sternum  is  made  to  project  forward,  and  this  is  called pt^reon- 
bj-east,  or  pectus  carinatum.  The  weakest  part  of  the  thorax  is  at  the 
junction  of  the  cartilages  and  ribs,  and  the  sternum  is  thus  naturally 
pushed  forward.  In  another  series  of  cases,  in  which  the  ribs  are  pushed 
together  laterally  and  the  sternum  depressed,  as  where  there  is  inter- 
ference with  the  entrance  of  air  into  the  lungs  by  adenoid  growths  and 
enlarged  tonsils,  the  condition  of  funnel  chest  is  produced,  as  seen  in  Fig. 
73,  page  283.  Again,  there  may  be  greater  compression  on  one  side 
than  on  the  other,  with  a  resulting  prominence  or  depression  on  one  side 

of  the  sternum. 

21 


3-22 


PEDIATRICS. 


The  costal  cartilages  are  frequently  enlarged  at  their  junction  with  the 
ribs,  and  can  be  felt  and  often  seen  as  a  line  of  rounded  prominences. 


Fig.  81. 


Inner  surface  of  sternum,  with  cartilages  and  portions  of  ribs  attached,  showing  rhachitic  rosary. 

These  prominences  are  called  the  rhachitio  rosary^  and,  though  most  com- 
monly occurring  in  the  latter  part  of  the  first  year,  have  also  been  met 

Fig.  82. 


l\liachitie  ky]>ho?is.     Fo.malo,  :'.  ycius 


with   in   the    early   weeks    of  life.     The   rhachitic   rosary,   according  to 
Morse's  observations  on  four  hundred  cases  at  the  Infants'  Hospital,  is 


DISEASES   OF   NUTRITION.  323 

the  earliest  of  the  physical  signs  of  rhachitis  to  develop,  and  is  the  most 
common  abnormality  in  rhachitis.  It  does  not  occur  in  normal  chil- 
dren, and  its  presence  justifies  the  diagnosis  of  rhachitis.  The  rosary 
is  sometimes  present  only  on  the  internal  surface  of  the  ribs,  as  seen  in 
Fig.  81.  -which  represents  a  case  in  which  the  rhachitic  rosary  could  not 

Fig,  83. 


Showing  deformities  of  the  humeri  in  a  case  of  rhachitis  of  an  infant  of  len  months,  due  to  the  habit,  on 
the  part  of  the  mother,  of  lifting  the  child  by  the  arms. 

be  detected  on  the  outer  surface,  xls  the  pathological  process  is  more 
pronounced  in  the  lower  ribs,  especially  the  lower  five,  than  the  upper, 
the  rosary  is  more  distinct  in  the  lower  ribs. 

Spine. — Deformity  of  the  spine  is  quite  constant  in  rhachitis  and  results 
mostly  from  muscular  weakness,  but  the  vertebrae  may  be  affected  by  the 
rhachitic  process,  and  in  cases  of  recovery  may  be  found  thickened.  The 
most  common  deformity  is  kyphosis,  which  consists  of  a  gradual  bowing 
backward  in  the  dorsal  and  lumbar  regions,  as  seen  in  Fig.  82. 

The  prominence  of  these  vertebral  spines  is  often  c|uite  sharp,  and  sim- 
ulates Pott's  disease,  but  the  rhachitic  spine  should  be  flexible  to  passive 
manipulation.  In  certain  cases,  however,  it  is  rigid.  Scoliosis  (lateral 
curvature)  and  lordosis  (forward  curvature)  are  common  deformities  oc- 
curring in  rhachitis. 

Extremities. — Deformities  of  the  long  bones  may  arise  in  the  epiphy- 
ses and  in  the  shafts  :  the  former  show  enlargement,  the  latter  bending. 
Enlargement  of  the  epiphyses  appears  especially  at  the  wrists  and  at  the 
anterior  ends  of  the  ribs  ;  enlargement  of  the  lower  end  of  the  radius  and 
ulna  is  practically  universal,  whereas  the  enlargement  of  the  lower  end 


324  PEDIATRICS. 

of  the  tibia  and  fibula  occurred  in  four  hundred  out  of  a  series  of  one 
thousand  cases.  The  increase  of  the  epiphyses  at  the  wrists  is  greater 
than  elsewhere.  These  enlargements  do  not  involve  the  joints.  In  the 
deep-seated  epiphyses,  like  the  hip  and  the  shoulder,  the  changes  are  not 
noticed  so  readily.  The  proliferating  layer  between  the  epiphyses  and 
the  bone  may  become  so  thick  and  softened  that  consequent  deformity 
and  separation  of  the  epiphyses  may  occur,  but  such  an  event  is  uncom- 
mon. When  fractures  occur  they  are  on  the  concave  side  of  the  bone. 
In  rhachitis  of  the  extremities  the  curve  of  the  forearm  may  be  due  to 
the  pull  of  the  muscles,  and  there  may  be  a  special  bend  of  the  radius 
about  the  ulna,  probably  secondary  to  the  anteroposterior  curve.  It 
prevents  full  supination.  The  humerus  rarely  bends.  Fractures  are  not 
rare.  Any  considerable  increase  in  the  ankle  epiphysis  is  rare.  The  curve 
of  the  femur  is  forward  or  forward  anteriorly,  so  that  in  the  latter  case 
there  may  be  no  curve  on  the  posterior  surface.  Fractures  may  occur 
with  excessive  callus.  In  the  lower  leg  fracture  takes  place  most  often 
with  anterior  bow-legs,  and  the  resulting  callus  is  less  than  in  the  thigh. 
Fractures  of  the  long  bones,  however,  are  uncommon,  but  their  arrested 
development  may  cause  permanent  shortening.  Bowing  of  the  legs, 
knock-knee,  and  flat-foot  are  all  very  common  symptoms  of  rhachitis. 
Coxa  vara  may  be  present.  Localized  rhachitis,  as  of  the  legs,  is  pos- 
sible and  quite  frequently  met  with  in  children  with  no  symptoms  of 
genera]  rhachitis.  It  is  not  unusual  to  find  hydrocephalus  combined  with 
rhachitis. 

Signs  of  previous  rhachitis  are  suggested  by  a  caput  quadratum  with  a 
thick  skull,  irregularity  of  the  teeth,  eversion  of  the  lower  edges  of  the 
thorax,  pigeon-breast,  pelvic  deformity,  deformities  of  the  clavicles  and  ex- 
tremities, and  thickened  epiphyses,  which  may  persist,  as  thickened  epiphy- 
ses in  general  are  slow  in  disappearing  and  outlast  the  active  process. 

The  existence  of  flat-foot  in  children  over  two  years  old  should  lead  to 
^n  examination  for  knock-knee.  The  combination  of  these  two  conditions 
will  in  most  cases  be  found  to  be  dependent  upon  present  or  previously 
existing  rhachitis. 

Muscles. — There  is  a  weak  and  relaxed  condition  of  the  muscles,  but 
microscopically  the  muscles  are  only  pale  and  their  fibres  infiltrated  with 
fat,  although  in  some  cases  there  may  be  atrophy  from  disuse. 

Nervous  System. — The  nervous  system  is  in  an  exceedingly  unstable 
and  sensitive  condition.  Convulsions  are  quite  common,  especially  in 
connection  with  craniotabes.  The  condition  of  spasm-  of  the  glottis 
(laryngospasmus),  although  it  may  occur  in  other  diseases,  is  especially 
characteristic  of  rhachitis.  The  infants  hold  their  breath,  grow  cyar^otic, 
are  seemingly  unconscious,  fall  back  entirely  limp,  and  after  a  few  min- 
utes recover.     Tetany  at  times  is  met  with  as  a  complication. 

Lungs. — Owing  to  deformities  of  the  thoracic  walls  there  is  a  tendency 
to  atelectasis  of  portions  of  the  lung  from  pressure,  with  surrounding  areas 


PLATE   A' 


Case  of  Rhachitis,  the  radiograph  showing  the  marked  deiormUy  (knocis-knee),  tlie  "zone  of  pro- 
liferation'" at  each  epiphyseal  line,  as  well  as  the  marked  rarefaction  of  the  shadows  cast  ty  all  the 
bones  due  in  all  probability  to  the  deficiency  in  lime  salts  as  well  as  to  the  change  of  function  as  to 
weight  hearing. 


DISEASES   OP   NUTRITION. 


325 


of  emphysema.  There  is  also  a  great  tendency  to  bronchitis  and  to 
bronchopneumonia. 

Heart. — The  heart  often  shows  signs  of  mechanical  irritation,  repre- 
sented by  irregularity  and  caused  by  deformities  of  the  thorax. 

Blood. — Unless  rhachitis  is  accompanied  by  a  secondary  anaemia,  the 
blood  is  practically  normal,  and  presents  no  other  characteristic  changes. 
Hock  and  Schlesinger  found  that  if  the  secondary  anaemia  was  moderate 
in   intensity,   and   diarrhoea  and  vomiting  occurred,  it  simply  made  the 

Fig.  84. 


>lil.    Kluu'hitis,  with  enlarged  spleen, 


anaemia  more  acute.  The  majority  of  the  leucocytes  were  found  to  be 
mononuclear  and  about  the  size  of  the  erythrocytes.  There  is  a  mod- 
erate permanent  leucocytosis  in  most  of  these  cases,  and  at  times  the 
mononuclear  leucocytes  seem  to  be  the  most  numerous  form. 

Spleen. — In  some  cases  the  spleen  is  found  to  be  enlarged,  but  it  is 
rarely  very  large,  unless  associated  with  severe  anaemia. 

The  following  case.  Fig.  84,  is  interesting  as  an  illustration  of  rhachitis 
with  a  secondary  anaemia  of  high  grade,  accompanied  by  enlargement 
of  the  spleen : 

The  child  was  three  years  old,  and  was  fairly  well  nourished.  It  had,  however, 
enlarged  epiphyses,  a  rhachitic  rosary,  the  square  rhachitic  head,  and  marked  bowing 
of  the  legs.  On  physical  examination  no  indication  of  enlargement  of  the  liver  or 
glands  was  found.  The  spleen  was  very  much  enlarged,  and  the  position  of  its  out- 
line and  its  notch  is  indicated  in  black.  The  blood  examination  showed  a  severe 
secondary  anaemia;  but  no  evidence  of  a  leucaemia. 

Liver. — The  liver  often  shows  fatty  infiltration,  and  is  at  times  en- 
larged but  less  frequently  than  the  spleen.  A  distinction  must  be  made 
in  these  cases  between  an  enlarged  liver  and  a  depressed  liver,  caused  by 
rhachitic  compression  of  the  thorax  and  narrowing,  or  from  relaxation 
of  the  natural  ligamentous  supports  as  a  result  of  the  weakness  from  the 
general  inanition  which  affects  all  the  tissues  of  the  body. 

Lymph-nodes. — The  lymph-nodes  are  very  frequently  found  to  be 
enlarged  from  simple  hyperplasia. 


a:>(J  PEDIATRICS. 

Stomach  and  Intestine. — There  is  usually,  though  not  necessarily, 
functional  disturbance  of  digestion  ;  also  a  subacute  catarrhal  condition  and 
a  tendency  to  gastric  dilatation.  The  symptoms  vary  very  much  and  diar- 
rhoea and  constipation  alternate.  Marfan  thinks  that  the  intestine  is  elon- 
gated in  rhachitis.  The  distended  abdomen  results  from  weakness  of  the 
muscles  of  the  abdominal  wall  and  of  the  intestine,  and  a  resulting  um- 
bilical hernia  is  quite  common.  In  like  manner  atonic  constipation  is 
common. 

Diagnosis. — The  diagnosis  of  rhachitis  cannot  be  made  by  the  pre- 
monitory symptoms,  as  the  disease  is  so  often  the  result  of  impaired 
nutrition  arising  from  many  causes,  that  it  is  difficult  to  determine  when 
the  rhachitic  symptoms  begin.  The  differential  diagnosis  has  to  be  made 
from  a  number  of  diseases  in  which  the  general  nutrition  of  the  child  is 
profoundly  disturbed,  these  diseases  being  especially  represented  by  func- 
tional disorders  connected  with  the  gastro-enteric  tract.  When  the  patho- 
genic changes  in  the  bones  have  progressed  sufficiently  for  physical  detec- 
tion, and  the  disease  is  fully  developed,  the  diagnosis  is  not  difficult.  In 
its  early  stages,  therefore,  the  manifestations  of  rhachitis  may  be  so  slight 
that  the  diagnosis  must  often  be  held  in  abeyance. 

The  differential  diagnosis  of  rhachitis  is  to  be  made  from  chondro- 
dystrophy, scorbutus,  rheumatism,  osteomalacia,  osteomyelitis,  syphilis, 
paralysis  of  central  origin,  Pott's  disease,  and  from  the  disability  to  use  the 
limbs,  due  to  simple  weakness  in  infants  who  are  not  rhachitic. 

Chondrodystrophy^  or  Achondroplasia,  is  distinguished  from  rhachitis 
in  the  following  characteristics  :  The  trunk  is  normal,  while  the  extremities 
are  short  and  deformed.  The  head  is  large  and  the  bridge  of  the  nose 
flattened.  The  enlargements  at  the  ends  of  the  long  bones  are  due  to 
overgrowth  of  the  periosteum,  instead  of  to  changes  in  the  epiphyseal 
cartilage,  and  the  zone  of  proliferation  is  narrower  than  that  in  rha- 
chitis. A  radiograph  will  usually  bring  out  the  differences  in  the  pathol- 
"^gy  of  the  chondrodystrophy  and  all  other  lesions  of  the  bones  which 
resemble  it. 

Scorbutus  is  eliminated  in  the  diagnosis  by  the  presence  of  the  various 
osseous  lesions  Avhich  have  just  been  descrUDed  as  symptoms  of  rhachitis, 
and  by  the  absence  of  the  characteristic  features  of  scorbutus,  represented 
by  tenderness  and  swelling  just  above  the  joints,  without  much  fever, 
subperiosteal  hemorrhages,  and  stomatitis  ulcerosa. 

Rheumatic  fever  in  its  articular  form  would  present  such  marked  symp- 
toms of  acute  tenderness,  swelling,  and  pain  in  the  joints,  combined  with 
a  heightened  temperature,  that  it  could  easily  be  distinguished  from  the 
general  tenderness  of  the  bones  without  much  fever,  together  with  the  sub 
acute  or  chronic  course  and  the  characteristic  enlargement  of  the  epiphyses 
in  rhachitis. 

Osteomyelitis. — The  clinical  symptoms  of  an  acute  infectious  disease, 
with  sudden  onset,  and  represented  by  severe  constitutional  disturbance. 


DISEASES    OF    NUTRITION.  327 

heightened  temperature,  pain,  locahzed  tenderness,  and  rapid  exhaustion, 
serve  to  distinguish  osteomyehtis  from  the  slow  development  and  slight 
amount  of  fever  met  with  in  rhachitis.  In  osteomyehtis,  moreover,  vari- 
ous foci  of  infection  will  appear  in  one  or  more  bones  with  tenderness  at 
these  points  and  a  tendency  to  suppuration  which  is  not  met  with  in 
rhachitis. 

Osteomalacia. — In  very  rare  cases  osteomalacia  occurs  in  children,  but 
it  can  seldom  be  differentiated  from  rhachitis  during  life. 

Hereditary  Syphilis. — The  diagnosis  of  rhachitis  from  hereditary  syph- 
ilis is,  as  a  rule,  not  difficult.  Syphilis  and  rhachitis  have  no  direct  con- 
nection with  each  other,  but  are  both  chronic  constitutional  diseases,  and 
it  is  possible  to  have  both  diseases  occur  in  the  same  individual.  While 
in  rhachitis  the  enlargement  of  tlie  long  bones  is  limited  to  the  epiphyses, 
in  syphilis  it  is  not  so  limited,  but  involves  the  ends  of  the  diaphyses. 
Tliis  enlargement  is  often  accompanied  by  a  condition  which  closely  simu- 
lates a  callus,  and  there  is  a  distinct  tendency  to  fracture  in  syphilis 
rather  than  to  the  bending  which  is  common  in  rhacliitis.  The  notched 
teetli  and  the  craniotabes  may  occur  in  botli  diseases,  while  the  lesions  of 
the  moutli  and  lips  described  on  page  527,  and  the  lesions  of  the  skin  on 
page  525,  are  distmctive  of  syphilis. 

Cerebral  Paralysis  and  Poliomyelitis. — In  certain  cases  of  rhachitis,  es- 
pecially in  tlie  earlier  stages,  the  so-called  paralysis  of  rhachitis  occurs, 
and  must  be  distinguished  from  paralysis  of  central  origin,  especially  from 
poliomyelitis  of  the  cord.  The  differential  diagnosis  must  be  made  by 
the  absence  of  the  symptoms  described  under  cerebral  paralysis  and  polio- 
myelitis described  on  pages  950  and  958,  and  by  an  examination  of  the 
child  in  a  recumbent  posture,  which  in  rhachitis  will  show  that  the  muscu- 
lar movements  are  but  little  impaired,  that  the  apparent  inability  to  move 
the  limbs  and  the  disinclination  to  walk  are  caused  by  tenderness  of  the 
bones  and  muscular  weakness,  that  the  electrical  reaction  is  normal,  and 
that  the  reflexes  are  not  affected.  This  pseudo-paralysis  is  certain  to  pass 
off  if  the  child  lives.  Cases  of  rhachitis  which  do  not  walk  until  late,  on 
account  either  of  muscular  weakness  or  of  tenderness,  may  resemble 
cases  of  organic  nervous  disease  with  true  paralysis.  The  diagnosis  must 
rest  on  the  presence  of  the  general  signs  of  these  nervous  diseases. 

Potfs  Disease.— When  rhachitis  causes  kyphosis  of  the  spine  it  may 
simulate  Pott's  disease  very  closely.  A  prominence  may  be  present  at  the 
dorso-lumbar  junction,  which  is  a  frecfuent  seat  of  the  deformity  in  Pott's 
disease,  and  which,  involving  several  vertebrae,  may  or  may  not  be  oblit- 
erated when  the  child  lies  on  its  face  and  is  lifted  by  its  feet  from  the 
table.  The  spine  is  held  rigidly  in  severe  cases,  just  as  in  Pott's  disease, 
and  the  deformity  may  be  angular  rather  than  the  usual  gradual  curve. 
The  coexistence  of  enlarged  epiphyses  and  other  rhachitic  conditions 
makes  it  very  probable  that  the  affection  is  rhachitic  ;  but  both  diseases 
may  coexist. 


328  PEDIATRICS. 

In  general,  the  age  of  the  child,  under  eighteen  months,  the  absence  of 
much  pain,  and  the  existence  of  other  signs  establish  the  diagnosis  of 
rhachitis.  Rhachitis  is,  moreover,  in  children  under  two,  much  more 
common  than  Pott's  disease.  In  doubtful  cases  the  diagnosis  can  be  made 
only  after  several  examinations  and  a  period  of  two  or  three  weeks  of  re- 
cumbency, under  which  conditions  the  rhachitic  spine  becomes  somewhat 
more  flexible.     In  doubtful  cases  time  alorie  will  establish  the  diagnosis. 

^Veahless. — In  certain  infants  who  are  not  rhachitic  the  power  of 
walking  is  lost  for  variable  periods,  and  is  due  to  weakness  following  any 
disease,  whether  acute  or  chronic,  which  for  a  time  n:iay  interfere  with 
the  infant's  vitality.  This  condition  is  difficult  to  distinguish  from 
rhachitis,  but  must  be  differentiated  by  the  absence  of  other  symptoms 
of  rhachitis.  Delay  in  learning  to  walk  should  lead  us  to  carefully  ex- 
amine for  other  symptoms  of  rhachitis,  as  it  is  quite  often  one  of  the 
manifestations  of  this  disease.  An  open  fontanelle  after  the  nineteenth  or 
twentieth  month  suggests  rhachitis,  and  delayed  dentition  is  also  signifi- 
cant. If  there  are  no  teeth  at  the  ninth  or  tenth  month,  the  infant 
should  be  carefully  examined  for  rhachitis ;  at  one  year  absence  of  teeth 
almost  always  indicates  the  disease.  Finally,  the  rhachitic  attitude  of  an 
infant  with  well-marked  rhachitis  is  characteristic,  and  is  shown  in  Fig.  85, 
facing  page  328. 

The  infant  stands  with  its  thighs  flexed,  knees  bent,  back  arched, 
shoulders  thrown  back,  prominent  abdomen,  head  rather  rigid,  legs  apart, 
and  varying  degrees  and  combinations  of  bow-legs  and  knock-knee  with 
flat-foot.  The  cause  of  this  attitude,  according  to  Lovett,  may  in  a 
measure  be  a  persistence  of  the  infantile  position  which  children  assume 
when  they  are  learning  to  walk. 

Children  with  rhachitis  have  weak  muscles  as  well  as  weak  bones, 
and  the  condition  of  such  a  child  approaches  that  of  one  who  stands  and 
walks  with  the  least  expenditure  of  muscular  force. 

Hydrocephalus. — The  diagnosis  between  the  rhachitic  head  and  the 
hydrocephalic  is  usually  not  difficult.  The  former  is  irregularly  enlarged, 
flattened  on  top,  square-looking,  due  to  the  prominence  of  the  frontal 
bosses,  and  has  a  normally  tense  or  depressed  fontanelle.  The  latter  is 
regularly  enlarged  and  rounded,  with  prominent  parietal  bosses  and  a  tense 
and  bulging  fontanelle. 

The  appearances  of  the  bone  structure  as  differentiated  by  means  of 
the  Rontgen  rays,  in  certain  of  the  chronic  conditions  of  childhood,  may 
be  summarized  as  follows  : 

Rhachitis. — The  characteristic  curves  of  the  long  bones  are  easily 
apparent.  There  is  great  irregularity  at  the  epiphyseal  lines,  with  much 
hyperplasia  of  the  osteoid  tissue  and  hypertrophy  of  the  epiphyseal  carti- 
lages. These  pathological  changes  usually  give  the  appearance  of  a  great 
disproportion  between  the  bony  epiphysis  and  the  epiphyseal  ends  of  the 
diaphysis.     The  curves  in  the  shafts  of  the  bones  are  often  sharp. 


Fig.  85. 


RhacMtis.     Age.  6  year* 


DISEASES   OF   NUTRITION.  329 

Chondrodystrophy  Fcetalis. — In  this  condition  the  epiphyseal  Unes, 
instead  of  being  irregular,  are  straight,  although  much  narrowed.  The 
shafts  of  the  bones  are  often  thickened  and  stunted,  Avhile  the  apparent 
overgrowth  of  the  bony  epiphysis  is  so  marked,  that  its  shadow  often 
appears  to  overlap  that  of  the  epiphyseal  line. 

Osteomalacia  and  Osteoporosis. — These  are  met  with  later  in  life,  usually. 
The  lack  of  lime  salts,  as  is  shown  by  the  "  quality  "  of  the  shadow,  is 
generally  well-marked.  The  deformities  of  the  bone-shafts  are  characterized 
by  bendings  rather  than  sharp  curves. 

Tuberculosis. — Abnormal  shadows  attributed  to  tuberculosis  are  to  be 
seen  most  often  involving  the  joints,  although  the  appearances  in  the 
adjacent  bones  are  characteristic.  These  are  the  thin,  poorly-organized 
shadows  of  ill-nourished  bone  with  a  deficiency  of  lime  salts.  If  foci 
(areas  of  definite  necrosis)  appear,  they  are  prone  to  involve  the  epiphyses, 

OsteornyeUtis. — Here  the  abnormal  shadows  are  to  be  seen  in  the 
diaphysis,  and  are  generally  due  to  irregular  necrotic  areas,  with  or  with- 
out sequestra.  There  is  usually  no  thinning  of  the  shadows  of  the 
involved  bone  or  surrounding  bones. 

Prognosis. — The  prognosis  of  rhachitis  is  favorable,  provided  no  com- 
plications arise.  When  left  untreated  the  disease  may,  after  a  decided  de- 
gree of  deformity  has  occurred,  be  arrested  spontaneously,  the  pathologi- 
cal process  in  the  bones  cease,  and  the  bones  harden  in  their  deformed 
condition  (Lovett).  In  these  untreated  cases  the  younger  the  child  the 
more  unfavorable  is  the  prognosis.  A  spontaneous  arrest  of  the  disease 
may  take  place  in  any  of  its  stages,  but,  as  a  rule,  if  the  affection  is  at  all 
pronounced,  serious  deformities  are  usually  produced.  If  a  hydrocephalic 
condition,  which  at  times  appears  in  rhachitis,  is  present  to  any  degree,  if 
there  is  much  diarrhea,  or  if  the  infant  is  subject  to  frequent  attacks  of 
bronchitis,  the  prognosis  is  very  unfavorable.  Rhachitic  children  are  more 
liable  to  die  than  other  children  when  they  are  attacked  by  such  diseases 
as  pneumonia  or  bronchitis.  Attacks  of  the  acute  exanthemata  are  of 
serious  import  in  these  cases.  Rhachitic  children  are  especially  liable  to 
the  invasion  of  the  tubercle  bacillus.  According  to  Bradford  and  Lovett, 
kyphosis  disappears  under  proper  treatment.  Lateral  curvature  is  per- 
manent when  not  treated.  As  a  rule,  the  epiphyseal  enlargements 
diminish  with  growth,  but  to  a  certain  degree  remain  through  life.  The 
craniotabes,  laryngismus  stridulus,  bronchitis,  diarrhcea,  and  paralysis 
in  the  favorable  cases  gradually  pass  away.  Although  rarely,  death 
may  occur  in  attacks  of  laryngospasmus  and  convulsions  in  rhachitic 
infants. 

When  properly  treated,  the  health  of  rhachitic  children  improves 
slowly,  and,  unless  the  deformities  which  have  occurred  in  the  bones  have 
advanced  too  far,  more  or  less  complete  recovery  usually  takes  place  in 
the  third  or  fourth  year.  The  arrest  of  the  disease  at  an  early  stage  is 
important. 


;>30  PEDIATRICS. 

Treatment. — The  treatment  of  rhachitis  is  essentially  dietetic  and 
hygienic.  The  infants  should  be  kept  in  the  open  air  as  much  as  possible, 
and  should  live  in  rooms  accessible  to  sunlight.  The  food  should  be 
adapted  to  the  age,  according  to  the  rules  given  for  the  feeding  of  normal 
infants  during  the  first  two  years  of  life.  Milk,  cream,  eggs,  meats  and  cod- 
liver  oil  should  be  freely  given  within  the  limits  of  the  child's  digestion. 
There  does  not  appear  to  be  any  drug  which  produces  a  specific  effect  upon 
the  osseous  changes  which  take  place  in  rhachitis.  Stoeltzncr,  after  study- 
ing the  treatment  of  rhachitis  in  Fleubner's  clinic,  states  that  the  extract  of 
the  suprarenal  gland  influences  very  favorably  the  general  condition  of  the 
patient,  the  craniotabes  and  vasomotor  excitability.  The  softness  of  the 
thoracic  bones  disappears  rapidly,  delayed  teeth  appear  and  muscular 
strength  is  increased.  The  epiphyseal  enlargements  and  deformities  of  the 
head,  thorax  and  extremities  are  not  changed  by  use  of  this  drug.  Person- 
ally, we  have  had  no  experience  with  this  method  of  treatment.  Phosphorus 
is  considered  by  some  observers  to  be  a  valuable  adjunct  to  the  general 
dietetic  and  hygienic  treatment,  but,  according  to  our  experience  at  the 
Children's  Hospital,  it  has  not  proved  to  be  of  any  especial  benefit. 

When  the  ansemia  is  marked,  iron  in  some  form  should  be  given,  and 
at  times  an  increase  in  the  fat  in  the  food  seems  to  be  beneficial.  Espe- 
cial attention  should  be  paid  to  the  correction  of  deformities  by  exercises 
and  if  necessary  by  surgical  interference.  Whenever  any  tenderness  or 
pain  is  noticed,  the  infant  should  at  once  have  orange-juice  given  to  it.  as 
directed  in  scorbutus  (page  338). 

Laryngospasmus  should  be  promptly  treated  by  sprinkling  the  face 
and  chest  with  cold  water  and  by  lightly  slapping  the  back. 

Convulsions  should  be  treated  with  unusual  care  in  a  rhachitic  child, 
in  whom  they  usually  arise  from  depression  and  resulting  over-sensitive 
condition  of  the  nervous  system.  Stimulants  are  usually  indicated  in 
these  cases. 

Fig.  85,  I.  and  II.,  page  328,  represents  unusually  well  the  deformities 
in  the  bones  which  may  arise  as  a  result  of  rhachitis. 

The  boy  was  six  years  old.  He  was  nursed  from  the  breast  for  two  years,  and 
then  given  a  general  diet.  He  began  to  walk  when  fourteen  months  old,  and  the 
mother  noticed  that  his  legs  began  to  bend  at  about  that  time,  but  could  give  very  little 
information  about  the  course  of  the  disease.  The  physical  examination  showed  the 
heart's  impulse  to  be  about  on  the  level  with  the  sixth  rib  and  in  the  mammillary 
line.  The  heart's  sounds  were  clear  and  loud.  Nothing  abnormal  was  detected  in  the 
throat  or  lungs.  The  abdomen  was  large,  prominent,  and  tympanitic  ;  the  liver  was 
palpable  three  fingers'  Jjreadlh  below  the  ribs  in  the  mammillary  line  ;  the  spleen  was 
not  palpable. 

Looking  at  the  child  from  in  front,  as  represented  iu  Fig.  85,  I.,  the  head  was 
square  with  enlarged  frontal  prominences.  There  was  a  decided  bowing  of  the  left 
clavicle  with  enlarged  epiphyses  of  the  wrists  and  ankles,  outward  bowing  of  the  femora, 
and  flat-foot  with  extreme  pronation.  The  side  view,  as  represented  in  Fig.  85,  II., 
shows  the  flattened  top  of  the  skull,  rhachitic  rosary,  distended  abdomen,  lordosis,  an- 
terior bowing  of  the  tibial,  and  flat-foot. 


DISEASES    OF    XUTRITIOX.  331 

OHONDRODYSTROPHIA   FCETALIS. 

Choiidrodystrophia  foetaJis  is  a  disease  of  the  osseous  system,  begin- 
ning in  intra-uterine  life,  between  the  tliird  and  sixth  months,  and  usually 
ending  at  birth.  The  elTects  persist  throughout  life.  Owing  to  similar 
macroscopic  appearances,  it  is  often  erroneously  classified  as  foetal  rha- 
chitis,  but  microscopically  it  presents  marked  differences.  The  cause  is 
not  known.  It  is  usually  accompanied  by  general  malnutrition  and  the 
majority  of  cases  die  soon  after  birth.  The  less  severe  cases  do  not 
interfere  with  life. 

The  characteristic  changes  in  the  bones  result  in  shortened  and  de- 
formed extremities,  a  large  square  head  and  flattened  nose,  but  the  trunk 
usually  remains  normal.  These  abnormalities  are  brought  about  by  a 
disturbance  in  the  normal  processes  of  ossification  of  the  primary  carti- 
lages. The  flattening  of  the  bridge  of  the  nose  is  due  either  to  premature 
tribasilar  synostosis,  or  to  failure  of  development,  which  causes  the  base  of 
the  skull  to  be  shortened.  In  the  long  bones,  a  cartilaginous  ossification 
of  the  epiphyses  results  in  arrest  of  development  and  consecjuent  short- 
ening. The  shafts  consist  chiefly  of  periosteal  bone,  while  the  medullary 
canal  is  sometimes  replaced  by  hard  bone.  The  ends  may  be  so  affected 
by  the  overgrowth  of  periosteum  as  to  produce  enlargements  which  closely 
resemble  those  of  rhachitis.  Similarly  there  may  be  bending  at  the 
junction  of  the  ribs  and  cartilages,  flattening  of  the  sides  of  the  chest,  and 
a  contraction  and  flattening  of  the  pelvis. 

Kaufmann  has  divided  chondrodystrophia  foetalis  into  three  types  :  (1) 
chondrodystropliia  hypoplastica,  in  which  there  is  a  failure  of  develop- 
ment of  the  cartilage ;  (2)  chondrodystrophia  malacica,  in  which  there  is 
abnormal  softening  of  the  cartilage  ;  and  (3)  chondrodystrophia  hyper- 
plastica,  in  which  there  is  excessive  development  of  the  cartilage  in  all 
directions.  Osteoporosis  and  osteosclerosis  may  occur  as  complications  in 
any  case.     The  tendency  to  deformities  may  be  increased  by  fractures. 

In  rhachitis  the  enlargement  of  the  ends  of  the  long  bones  is  due  to 
excessive  development  of  the  epiphyseal  cartilage,  instead  of  to  an  over- 
growth of  the  periosteum.  The  zone  of  proliferation  is  also  widened  in 
rhachitis  instead  of  narrowed,  as  in  chondrodystrophia,  and  the  vasculari- 
zation is  marked. 

There  is  probably  no  direct  relation  between  chondrodystrophia  and 
cretinism. 

The  differentiation  between  rhachitis,  chondrodystrophia,  osteomalacia 
and  other  diseases  of  the  bone  by  means  of  X-rays  is  given  on  page  328. 

A  case  of  chondrodystrophia  foetalis  was  seen  in  consultation  with 
Dr.  Townsend. 

The  parents  were  young  and  healthy,  and  there  was  no  history  of  syphihs  or  rha- 
chitis. The  father  was  American,  the  motlier  Scotch.  There  was  one  other  child, 
three  years  old,  strong  and  well.  The  mother  during  her  pregnancy  was  much  wor- 
ried, and  her  nourishment  was  both  insufficient  and  poor.     The  infant,  a  male,  was 


332 


PEDIATRICS. 


one  month  premature.     The  labor  was  easy.     The  infant  weighed  seven  pounds  and 
was  43.3  cm.  (17  inches)  in  length. 

Fig.  86  represents  a  photograph  taken  on  the  fourth  day  of  the  infant's  life.  The 
head  was  square  in  front,  and  much  flattened  behind,  and  measured  33.8  cm.  (13} 
inches).  The  sutures  were  all  widely  open.  The  ossified  portions  of  all  the  bones  of  the 
skull  were  small,  particularly  of  the  occipital  bone,  which  presented  a  large  area  of 


Fig.   8( 


Chondrodystrophia  foetalis.    Age  -i  days. 

craniotabes.  In  the  widely-opened  sagittal  suture  just  back  of  the  anterior  fontanelle 
was  a  large  Wormian  bone  2.7  cm.  (1  inch)  long.  In  the  squamous  and  coronal  su- 
tures on  the  right  side  at  least  eight  small  Wormian  bones  could  be  easily  felt,  and  on 
the  left  side  eleven  were  counted.  The  thorax  was  30  cm.  (11  f  inches)  in  circum- 
ference, and  was  depressed  laterally,  the  depression  increasing  with  each  inspiration, 
owing  to  an  accompanying  atelectasis  in  the  lower  portions  of  the  lungs.  There  was 
considerable  cyanosis.  No  cardiac  murmur  was  detected.  A  rosary  was  present. 
The  abdomen  measured  at  the  level  of  the  umbilicus  28.7  cm.  (11}  inches).  There 
Avas  a  large  double  inguinal  hernia.  The  spleen  could  not  be  detected  on  examination. 
The  liver  could  be  felt  below  the  edge  of  the  ribs,  but  was  apparently  not  enlarged. 
There  were  marked  enlargements  of  all  the  epiphyses,  curvature  of  all  the  long  bones, 
and  numerous  fractures.  The  humeri  showed  a  slight  anterior  curvature.  The  bones 
of  each  forearm  were  also  bent  anteriorly.  The  femora  were  curved  outward  and 
forward.  The  lower  legs  showed  marked  angular  curvatures  forward  at  the  junction 
of  the  middle  and  lower  thirds.  The  fractures  were  apparently  of  as  recent  origin  as 
the  birth,  as  some  of  them  proceeded  to  unite  very  quickly.  On  the  eighth  day  the 
fracture  of  the  right  tibia  was  quite  firmly  united  ;  and  only  a  slight  crepitus  could  still 
be  felt  over  the  left  tibia.  The  fracture  of  the  left  humerus  was  firmly  united  with  a 
ring  of  callus.  The  right  humerus  at  birth  showed  a  callus  about  the  middle  of  the 
shaft :  this  was  evidently  the  repair  of  an  intra-uterine  fracture.  The  child  died  on  the 
ninth  dav  after  birth. 


The  following  case  of  chondrodystrophia  foetalis  occurred  in  our  clinic 
at  the  Children's  Hospital,  Fig.  87: 

The  child  was  five  and  a-half  years  old.     Her  ancestral  history  was  good.     One 
other  child  died  at  the  age  of  six  months  of  ' '  stomach  trouble, ' '  and  another  at  the  age 


DISEASES   OF   NUTRITION. 


333 


of  two  weeks,  of  cause  unknown.  She  had  not  grown  since  she  was  fifteen  months  old. 
She  began  to  talk  at  the  age  of  one  and  one-half  years.  She  had  measles  four  weeks 
previously,  but  no  other  sickness.      She  goes  to  school  and  is  considered  very  bright. 

Fig.  87. 


Chondrodystrophia  foetalis  in  a  girl  of  53^  years. 

The  only  complaint  was  retarded  growth.  No  organic  lesions  were  detected,  and  th^ 
urine  and  blood  were  negative.  The  following  measurements  show  the  rate  of  growth 
in  three  years  : 


November,  1902. 

Inches. 

Length 26 

Circumference  head ....  19 

Circumference  chest ....   17 

Circumference  abdomen  17j 

Circumference  thigh..  .   10^ 

Circumference  calf 7 


November,  1905. 

Inches. 
32 

February,  1906. 

Length  humerus 

Length  forearm 

Length  wrist  and  hand 

Length  femur 

Length  tibia 

cm. 
14.5 

20 

19 

18J 

10.5 

6.5 

17.0 

13J 

8h 

18  0 

Length  ankle  and  foot. 

3.5 

Fcetal  rhachitis,  or  congenital  rhachitis,  probably  occurs  as  a  disease 
.distinct  from  chondrodystrophia,  but  it  is  exceedingly  rare,  and  many  of 


334  PEDIATRICS. 

the  reported  cases,  in  the  light  of  our  present  knowledge,  would  now  be 
classed  as  chondrodystrophia  foetal  is. 

The  skeleton  at  birth  is  still  in  its  formation  stage,  e:id  it  is  therefore 
difficult  to  distinguish  between  the  effects  of  disease  and  those  of  malfor- 
mations. The  nomenclature  of  fostal  bone  disease  has  been  greatly  con- 
fused. The  same  name  has  been  given  to  different  pathological  and 
clinical  conditions  and  different  names  to  the  same  disease.  It  has  been 
suggested  by  Vrolik  that  foetal  bone  diseases  be  grouped  under  the  head  of 
"osteogenesis  imperfecta."  Irregularities  in  the  sutures  and  fontanelles 
are  not  to  be  regarded  as  conclusive  evidence  of  rhachitis  as  they  are 
often  due  to  retarded  development.  While  admitting  the  existence  of 
congenital  or  f(ietal  rhachitis,  we  cannot  at  present  describe  it  so  definitely 
as  to  clearly  differentiate  it  from  the  conditions  which  closely  resemble  it. 

OSTEOMALACIA. 

Osteomalacia  is  a  disease  which  occasionally  occurs  in  children,  but 
not  so  frequently  as  in  adults.  It  causes  softening  of  the  bones,  and  in 
this  respect  is  somewhat  similar  to  rhachitis. 

Etiology. — Nothing  definite  is  known  about  the  cause,  and  it  is  simply 
spoken  of  in  connection  with  diseases  of  nutrition  on  account  of  its  re- 
semblance to  rhachitis. 

Pathological  Anatomy. — There  is,  according  to  Ziegler,  an  absorption 
of  lime-salts,  beginning  first  at  the  medullary  cavity  and  proceeding  out- 
ward. The  epiphyses  are  not  notably  affected  by  the  continuance  of  the 
absorptive  process,  the  cortical  bone  becomes  spongy  and  decalcified,  and 
in  the  severest  cases  there  may  remain  little  but  marrow  and  periosteum 
(J.  C.  Warren,  "  Surgical  Pathology  "). 

The  opinion  is  generally  held  that  in  osteomalacia  the  layer  of  osteoid 
tissue  results  from  decalcification,  Avhile  in  rhachitis  a  similar  layer  repre- 
sents a  new  growth  deficient  in  lime-salts.  The  periosteum  is  likely  to 
be  thickened  and  vascular,  and  the  medulla  resembles  that  in  infancy  in 
its  gross  appearance. 

Symptoms. — Spontaneous  fractures  and  various  distortions  may  occur 
in  osteomalacia,  and  the  thorax  is  flattened  laterally. 

Treatment. — The  treatment  is  the  same  as  in  rhachitis  (page  330). 

SCORBUTUS. 

Scorbutus  (scurvy)  is  a  constitutional  disease  closely  associated  with 
imperfect  nutrition  and  having  a  definite  relation  to  the  deprivation  of 
the  individual  of  fresh  food.  It  is  characterized  by  anaemia  and  a  ten- 
dency to  hemorrhage,  and  in  most  cases  is  accompanied  by  the  condition 
of  the  gums  which  is  present  in  stomatitis  ulcerosa. 

Etiology. — In  addition  to  the  view  that  thfe  cause  of  scorbutus  is  of 
chemical  origin,  owing  to  the  significant  relation  Avhich  the  disease  has  to 


DISEASES    OF    MJTRITION.  335 

a  lack  of  fresh  food,  it  is  supposed  lliat  there  may  be  a  special  micro- 
organism which  causes  the  disease.  This,  however,  has  not  been  proved, 
and  we  have  no  further  knowledge  regarding  the  etiology  of  scorbutus. 

In  our  experience  there  is  no  evidence  that  sterilized  milk  is  a  cause  of 
scorbutus.  If  the  milk  is  properly  modified  it  can  be  heated  to  68.3°  C. 
(155°  F.)  or  even  higher,  without,  so  far  as  we  are  aware,  having  a  dele- 
terious effect  upon  the  osseous  system.  Long  continued  use  of  boiled  milk 
is,  however,  open  to  serious  objection. 

Many  cases  of  scorbutus  which  develop  in  bottle-fed  babies  are  at  least 
partly  dependent  upon  the  improper  composition  of  the  food.  We  cannot 
say  what  element  is  at  fault,  but  modifications  which  are  too  weak,  or  in 
which  the  total  cjuantity  taken  in  twenty-four  hours  is  too  small,  and  is 
continued  for  a  long  period,  may  be  followed  by  symptoms  of  scorbutus. 
We  have  seen  cases  of  previously  healthy  babies  who,  because  of  un- 
usually prolonged  irritation  from  difficult  dentition,  took  such  small 
quantities  of  food  in  twenty-four  hours  that  they  developed  the  early 
symptoms  of  scorbutus  within  a  few  weeks.  The  disease  is  most  fre- 
quently seen  in  infants  fed  on  patent  desiccated  foods  mixed  with  improper 
proportions  of  cow's  milk.  Cases  have  been  reported  in  breast-fed  babies. 
Hygiene  plays  a  very  small  part  in  the  etiology,  as  the  disease  is  more 
commonly  seen  in  the  well-to-do  than  in  the  very  poor.  Miller  reports  an 
interesting  case  of  a  healthy  infant  of  twelve  months,  who  was  weaned 
because  of  an  attack  of  acute  indigestion  and  put  upon  condensed  milk  and 
barley-water.     It  took  only  seven  weeks  of  this  diet  to  produce  scorbutus. 

Pathological  Axatomy. — So  few  post-mortem  examinations  have  as 
yet  been  made  on  infants  dying  of  scorbutus  that  the  pathological  lesions 
have  not  yet  been  finally  established.  A  sufficient  number  of  autopsies, 
however,  has  been  reported  by  Barlow  and  others,  notably  Northrup,  to 
settle  at  least  the  more  important  features  in  the  pathology  of  infantile 
scorbutus. 

There  are  no  alterations  in  the  blood,  either  anatomical,  chemical,  or 
bacteriological,  which  can  be  considered  peculiar  to  scorbutus.  There 
are  deep  hemorrhages  into  the  muscles  and  occasionally  about  or  even 
into  the  joints,  but  the  hemorrhage  in  infantile  scorbutus  is  essentially 
subperiosteal  and  chiefly  of  the  long  bones.  The  femora  are  most  com- 
monly affected,  and  there  is  a  tendency  to  separation  of  the  epiphyses. 
There  may  also  be  a  varying  amount  of  interstitial  hemorrhage  in  the 
lungs,  spleen,  kidney,  and  intestinal  glands.  Haematuria  has  been  noticed 
in  a  certain  number  of  cases  of  scorbutus,  and  it  is  wel'  to  examine  the 
urine  in  cases  in  which  the  disease  is  suspected.  Hemorrhages  into  the 
mucous  surfaces  are  usually  present,  the  gums  being  chiefly  affected  and 
presenting  the  condition  of  stomatitis  ulcerosa. 

Fig.  89  represents  a  section  of  the  bones  of  the  leg  in  a  case  of  infantile  scorbutus 
which  Avas  under  the  care  of  Dr.  Northrup,      On  examination  it  will  be  seen  that  the 


336 


PEDIATRICS. 


femur  is  normal  at  its  upper  extremity.  The  lower  half  is  invested  with  a  black, 
grumous,  subperiosteal  layer  of  blood.  The  lower  epiphysis  is  detached,  and  the 
lower  end  of  the  shaft,  macerated,  eroded,  and  soft,  is  lying  loose  in  the  black,  disin- 
tegrating blood-clot.  The  tibia  is  surrounded  by  thin,  dark,  hemorrhagic  layers  be- 
neath the  periosteum,  and  the  proximal  portions  are  congested.  The  fibulae  and  the 
bones  of  the  upper  extremities  were  normal. 

Fig.  88  represents  a  microscopic  section  of  this  bone,  wliich  shows  no  syphilitic  or 
rhachitic  changes  in  the  bone  or  the  periosteum. 

Fig.  88. 


Hem.  Per. 


Section  of  scorbutic  bone.    Med.,  medulla;  B,  bone;  Hem.,  hemorrhage;  Per.,  periosteum. 

The  soft  macerated  bone  gave  no  evidence  of  suppuration,  but  there  was  a  mod- 
erate congestion  of  the  femur  and  the  upper  extremity  of  the  tibia. 

Symptoms. — The  symptoms  of  infantile  scorbutus  are  tliose  of  a  slow 
and  progressive  cacliexia.  The  infants  become  anaemic,  and  show  more 
or  less  gastro-enteric  disturbance  of  a  subacute  functional  type.  Profuse 
sweating,  especially  about  the  head,  at  times  slight  feverish  attacks,  and 
lessened  appetite,  are  among  the  early  symptoms.  The  temperature  may 
be  from  time  to  time  slightly  raised,  but  not  significantly  so.  The  first 
symptom,  however,  which  especially  attracts  the  attention  is  a  sensitive 
condition  of  the  bones.  The  infant  cries  when  the  affected  parts  are 
touched.  It  does  not  seem  to  suffer  pain  when  it  is  allowed  to  remain 
quiet,  but  as  the  disease  advances  the  expression  of  its  face  indicates  the 
fear  of  being  handled.  In  our  individual  experience  with  infantile  scor- 
butus, with  few  exceptions,  all  were  from  eight  to  twelve  months  of  age. 
We  have  met  with  no  cases  later  than  the  first  half  of  the  second  year, 
and  with  none  earlier  than  the  second  half  of  the  first  year. 

As  the  disease  progresses,  more  marked  symptoms  develop.  Swellings 
of  the  limbs,  usually  of  the  diaphyses  just  above  the  epiphyses,  appear. 


Fi(i.  89. 


Vertical  section  of  leg-  In  a  case  of  infantile  scorbutus.    The  red  areas  3rnnnri  tho  f 
lepresent  suhperiosteal  hemorrhages.    ^Specimen  preserved  in  the  mL  Z"  the  roTe"!  TflT'^ 
ciaus  and  Surgeons,  New  York.)  "^euiii  or  tne  College  of  Physi- 


DISEASES  OF   NUTRITION.  337 

These  swellings  are  most  common  and  most  prominent  in  the  legs,  but 
may  also  appear  in  the  bones  of  the  forearm.  They  are  usually  pyri- 
form  and  synmietrical  in  shape,  the  skin  oyer  the  swelling  being  more  or 
less  tense,  but  not  fluctuating.  There  is  commonly  some  tenderness  on 
pressure,  but,  as  a  rule,  no  especial  heat  of  the  affected  part.  The  pain 
and  swelling  do  not  seem  to  be  in  the  joint,  but  in  the  diaphysis  and 
epiphysis.  Signs  of  hemorrhage  may  occur  in  the  skin  over  the  affected 
parts,  appearing  at  first  as  small  blue  maculae  and  later  involving  larger 
areas,  as  though  a  deep  hemorrhage  were  coming  to  the  surface.  In 
advanced  cases  hemorrhage  may  take  place  to  such  an  extent  in  the 
deeper  parts  around  the  eyes  that  the  eyes  will  be  pushed  forward 
(proptosis). 

When  the  infant  has  not  cut  any  teeth,  the  mucous  membrane  of  the 
gums,  according  to  our  experience,  are  not  usually  affected  ;  but  when  a 
tooth  is  pressing  on  a  gum  and  is  almost  through,  or  even  when  a  small 
portion  of  a  tooth  has  penetrated  the  gum,  small  areas  of  congested  mu- 
cous membrane  appear,  and  are  of  great  aid  in  the  diagnosis.  In  some 
cases  a  few  hemorrhagic  maculae  appear  in  other  parts  of  the  skin,  as  in 
that  of  the  forehead. 

In  addition  to  the  symptoms  of  epiphyseal  pain,  the  infant  keeps  the 
affected  limb  perfectly  still,  so  that,  unless  it  were  understood  that  it  is 
pain  which  prevents  it  from  moving  the  limb,  it  might  be  supposed  that 
it  was  paralysis  ;  in  fact,  this  symptom  in  scorbutus  has  been  termed 
pseudo-paralysis.  It  has  nothing  to  do  with  true  paralysis,  and  corre- 
sponds to  what  is  seen  in  rheumatic  affections  of  the  joints. 

Diagnosis. — The  diagnosis  of  infantile  scorbutus  is  to  be  made  from 
rheumatic  fever,  rhachitis,  purpura,  syphilis,  and  acute  anterior  polio- 
myelitis. 

RheumatiG  Fever. — In  the  diagnosis  from  rheumatic  fever  the  absence  of 
heat  and  tenderness  of  the  joint  and  of  a  pronounced  rise  of  temperature 
is  usually  sufficient  to  distinguish  the  two  diseases. 

Rhachitis. — The  diagnosis  from  rhachitis  is  to  be  made  by  the  presence 
of  hemorrhages,  the  intense  pain  in  the  region  above  the  epiphyses,  the 
absence  of  a  rhachitic  rosary,  and  the  absence  of  symptoms  of  rhachitis 
when  it  is  not  coexistent.  If  teeth  are  present,  the  occurrence  of  stoma- 
titis ulcerosa  usually  makes  the  diagnosis  clear.  In  the  case  in  which 
rhachitis  is  present  the  symptoms  of  scorbutus  appear  to  complicate  a 
primary  rhachitis,  and  when  the  scorbutic  symptoms  pass  away  the  rha- 
chitic manifestations  remain. 

Purpura. — Purpura,  except  in  the  severe  forms  in  which  the  joints  are 
affected,  is  easily  differentiated  by  the  absence  of  the  peculiar  osseous 
symptoms  of  scorbutus. 

Syphilis. — Scorbutus  is  differentiated  from  syphilis  by  the  extreme 
tenderness,  the  hemorrhages,  and  the  commonly  occurring  stomatitis 
ulcerosa  which  occur  in  the  former  disease,  while  syphilis  has  distinctive 

22 


338  PEDIATRICS. 

symptoms  which  are  not  found  in  scorbutus,  ^\•llich  will  be  described  under 
the  former  disease. 

Acute  Anterior  Poliomyelitis. — The  differential  diagnosis  between  scor- 
butus and  acute  anterior  poliomyelitis  is  made  by  the  presence  in  the 
former  of  enlargement  and  tenderness  in  the  neighborhood  of  the  epipli- 
yses.  Pain  is  present  only  in  the-  initial  stage  of  acute  anterior  polio- 
myelitis, and  tenderness  is  absent.  In  acute  anterior  poliomyelitis,  also, 
the  onset  is  sudden,  and  there  are  uo  premonitory  symptoms. 

Prognosis. — Scorbutus  is  very  variable  in  its  duration.  If  left  un- 
treated, all  the  symptoms  may  become  more  pronounced  and  the  infant 
finally  die  of  exhaustion.  When  properly  treated,  and  uncomplicated  by 
any  other  disease,  the  prognosis  is  very  favorable  if  treatment  is  begun 
early  in  the  attack,  before  the  vitality  of  the  infant  has  been  too  much 
reduced. 

Treatment. — The  treatment  of  infantile  scorbutus  is  essentially  by 
changing  the  improper  food,  which  inmost  cases  is  being  given,  to  suitable 
modifications  of  fresh  milk  and  to  orange-juice.  Under  this  treatment  the 
pain  and  tenderness  of  the  limbs  rapidly  disappear,  sometimes  within  a 
few  days,  as  does  also  the  stomatitis  ulcerosa.  In  the  beginning  the  juice 
of  one  orange  should  be  given  during  the  twenty-four  hours.  It  usually 
is  well  to  dilute  the  orange-juice  one-third  with  water.  If  a  rapid  im- 
provement does  not  take  place,  a  still  larger  dose  should  be  given  within  a 
few  days.  These  scorbutic  infants  usually  take  orange-juice  with  avidity, 
but  they  should  be  forced  to  take  it  if  they  do  not  like  it.  The  nurse 
should  be  cautioned  to  move  the  affected  limbs  as  little  as  possible,  and 
the  infant  should  be  kept  on  a  comfortable  pillow  on  which  it  can  be 
carried  about. 

In  our  earlier  cases,  before  we  recognized  the  scorbutic  element  in  the 
disease,  we  treated  these  infants  with  a  number  of  drugs,  none  of  which 
appeared  to  have  the  slightest  beneficial  effect.  In  some  of  these  cases 
the  symptoms  grew  progressively  worse,  and  the  inft\nts  died.  In  one  of 
lem,  however,  in  whom  the  hemorrhages  in  the  skin  were  extensive  and 
proptosis  was  marked,  the  infant  recovered  entirely  when  a  properly 
modified  milk  Avas  substituted  for  the  artificial  food  which  it  had  been 
taking.  In  some  of  the  later  cases  which  we  have  seen  in  consultation, 
where  infants  living  in  the  country  with  good  hygienic  surroundings  were 
being  fed  on  one  of  the  many  artificial  foods,  the  disease  had  progressed 
to  such  an  extent  that  the  infants  were  extremely  aniemic,  had  hemor- 
rhages in  various  parts  c!  the  skin,  were  unable  to  take  any  food,  and  were 
seemingly  dying;  in  fad,  they  were  as  much  reduced  as  were  the  cases 
Avhich  we  have  just  spoken  of  as  having  terminated  fatally.  These 
infants,  after  taking  orange-juice  for  a  few  days,  invariably  improved 
rapidly,  and  usually  recovered  entirely  in  two  or  three  weeks. 

The  symptoms  which  iiave  been  described  are  well  represented  in  the 
following  case  and  in  Fig.  90  : 


DISEASES   OF   ^■UTRITIO^^  339 

The  infant,  a  female,  ten  months  old.  Avas  healthy  at  birth  and  weighed  3636 
grammes  (8  pounds).  It  was  nursed  at  first,  but  later  was  fed  on  a  patent  food,  on 
which  it  did  not  gain.  When  it  was  eight  months  old  it  lost  somewhat  in  weight,  had 
profuse  sweating,  and  began  to  have  tenderness  in  its  limbs.  It  had  six  teeth.  There 
was  an  expression  of  fear  on  its  face,  and  it  kept  its  arms  and  legs  perfectly  motionless. 

Fig.  90. 


luiamile  scorbutus.     (Second  month  of  disease.)     Female,  lu  months  old. 

Whenever  it  thouglit  that  ifs  legs  or  arms  were  going  to  be  touched  it  cried  with 
fear.  There  was  no  evidence  of  rhachitis  in  this  infant.  There  was  a  swelling  of  the 
diaphysis  just  above  the  epiphyses  of  the  bones  of  the  right  wrist,  and  also  in  the 
lower  part  of  the  femur  of  each  leg  and  the  lower  part  of  the  tibia.  The  swelling  did 
not  fluctuate,  had  a  hard,  tense  feeling,  and  apparently  was  not  connected  with  the 
joints.  There  was  no  increased  heat  of  the  skin,  but  there  were  certain  circumscribed 
areas  of  hemorrhage  in  the  skin  over  the  swellings.  The  gums  showed  the  condition 
of  stomatitis  ulcerosa  to  so  marked  a  degree  that  they  almost  covered  the  teeth.  They 
were  purple,  bled  easily,  and  were  very  similar  tr>  those  represented  in  Plate  XL, 
facing  page  620. 

The  infant's  diet  w^as  changed  to  a  modified  milk,  and  it  was  given  the  juice  of 
one  orange  daily  Within  two  days  it  moved  its  legs  and  arms  freely,  the  anxious  ex- 
pression left  its  face,  and  in  a  few  weeks  it  had  gained  much  in  weight  and  Avas 
perfectly  well. 

An  examination  of  the  blood  m  this  case  showed  only  a  secondary  an«mia. 

The  following  case  of  infantile  scorbutus  illustrates  an  extreme  degree 
of  subperiosteal  hemorrhage : 

A  boy  nine  months  old  came  to  the  out-patient  department  October  3,  1901.  He 
had  been  fed  for  the  first  five  months  on  Mellin"s  Food,  and  for  the  last  four  months  on 
Cereal  Milk  His  birth-weight  was  7^-  pounds  and  his  weight  at  the  time  of  the  first 
examination  was  9  pounds,  a  gain  of  li  pounds  in  nine  months.  The  family  hisloiv 
Avas  negative. 

The  four  Aveeks  before  entrance  he  became  fretful  and  irritable  and  the  loAver  ex- 
tremities became  sensitive.  One  Aveek  later  the  left  thigh  began  to  sAvell,  sAvellinas 
appeared  just  above  the  ankles  and  a  few  days  later  the  right  thigh  became  similarly 
affected.  The  SAvelling  of  the  thighs  progressed.  The  mouth  Avas  red  and  sensitive. 
Avhile  the  baby  Avas  cutting  two  loAver  incisors. 

On  September  26,  about  four  Aveeks  after  the  onset  of  the  .symptoms,  the  baby  Avas 
seen  in  the  out-patient  department  of  the  Children's  Hospital.     It  aa'us  emaciated.-  The 


340 


PEDIATRICS. 


anterior  fontanelle  measured  11  inches.  There  were  two  lower  incisors  and  a  general 
enlargement  of  the  lymph-nodes.  The  gums  showed  a  slight  purplish  tinge,  but 
no  typical  stomatitis  ulcerosa.  There  was  a  marked  rosary.  The  spleen  was  just 
palpable  and  the  liver  could  be  felt  two  fingers  breadth  below  the  costal  border.  The 
prominent  feature  of  the  case  was  the  marked  enlargement  of  the  thighs,  in  contrast  to 
the  emaciated  body,  especially  the  arms.  The  swellings  extended  from  epiphyses  to 
epiphyses,  being  especially  prominent  anteriorly.     There  was  no  limitation  of  motion 

Fig.  91. 


Infantile  Scorbutus  in  an  infant  of  9  months,  showing  extreme  sub-periosteal  hemorrhages  of   both 
femora,  with  slight  affection  of  the  lower  ends  of  both  tibiae. 


in  the  joints.  The  swellings  w^ere  apparently  connected  with  the  bone  ;  they  were  hard 
and  tense  and  somewhat  tender,  but  showed  no  heat  or  redness.  There  was  no  edema 
of  the  subcutaneous  tissue.  Above  the  left  inner  malleous  was  a  similar  swelling, 
much  less  advanced.  The  blood  showed  7,400  leucocytes.  There  was  no  pronounced 
pallor.  The  right  thigh  measured  8^  inches,  the  left  thigh  measured  7^  inches.  The 
treatment  consisted  of  plain  cow's  milk,  properly  modified,  and  orange  juice. 

/Subsequent  History.  —  There  was  considerable  difficulty  in  adjusting  the  food  to  the 


DISEASES    OF   XUTRITIOX.  341 

infant's  digestion,  but  the  swelling  and  tenderness  of  tlie  legs  rapidly  diminished  in 
spite  of  the  persistence  of  more  or  less  indigestion.  At  the  end  of  four  weeks  each 
thigh  had  diminished  nearly  two  inches  in  circumference  and  there  remained  no 
evidence  of  any  swelling  or  tenderness.  The  weight  was  still  9  pounds,  but  from  that 
time  the  baby  began  to  gain  on  a  fat,  2.50  ;  sugar,  6.00  ;  proteids,  1.00  ;  15  per  cent, 
lime-water  ;  10  ounces  barley  water  in  a  40-ounce  mixture.  There  were  six  feedings 
of  6  ounces,  gradually  increased  to  8  ounces. 

In  seven  weeks  the  infant  had  gained  3|  pounds.  The  food  was  then  rapidly  in- 
creased in  strength  and  quantity,  and  in  the  following  March,  4h  months  after  the 
beginning  of  treatment,  the  infant  weighed  17  pounds,  a  gain  of  9  pounds. 

The  history  just  given  was  that  of  an  advanced  case  of  infantile  scorbutus.  There 
were  certain  points  in  the  case,  however,  which  are  of  great  significance.  In  the  first 
place,  before  the  treatment  was  begun,  the  right  thigh  showed  not  only  considerable 
enlargement,  but  w'as  unyielding  to  pressure,  and  so  hard  that  it  strongly  suggested  the 
presence  of  osteosarcoma.  The  case,  therefore,  was  a  difficult  one  in  which  to  make  a 
differential  diagnosis,  and  it  had  even  been  suggested  by  some  who  saw  the  case  that  an 
amputation  for  osteosarcoma  would  be  needed.  It  is  presented  as  a  condition,  which, 
without  the  use  of  the  X-ray  and  with  the  absence  of  other  symptoms  of  scorbutus  and 
apparent  lesions  in  the  other  limbs  which  may  occur  in  infant  scorbutus,  would  make 
the  differential  diagnosis  between  osteosarcoma  and  subperiosteal  hemorrhage  very 
difficult. 

rNFANTILE  ATROPHY. 

Infantile  atrophy  (marasmus,  athrepsia)  is  essentially  a  disease  of 
infancy  and  early  childhood,  and  occurs  most  frequently  in  the  first 
six  months  of  life.  It  is  a  condition  in  which  extreme  atrophy  of  all 
the  soft  tissues  takes  place  without  demonstrable  disease  of  any  of  the 
organs. 

Etiology — Infantile  atrophy  is  apparently  the  result  of  a  vice  of  ab- 
sorption or  of  assimilation,  although  this  has  by  no  means  been  clearly 
proved.  The  wasting  which  occurs  as  the  result  of  malformations  of  tha 
mouth  and  throat  preventing  the  entrance  of  sufficient  food,  or  when  in- 
sufficient food  is  given,  should  be  considered  as  the  result  of  starvation. 
The  name  primary  infantile  atrophy  should  be  restricted  to  the  cases  in 
which  pronounced  and  persistent  atrophy  occurs  in  babies  who  have  been 
fed  upon  a  modified  milk  which  would  be  suitable  to  the  average  healthy 
infant  and  in  whom  no  underlying  disease,  such  as  chronic  indigestion, 
tuberculosis  or  syphilis,  exists.  The  wasting  which  occurs  as  a  result  of 
improper  feeding,  in  the  course  of  constitutional  diseases,  such  as  tuber- 
culosis or  syphilis,  or  as  the  result  of  severe  gastro-enteric  disturbance,  is 
to  be  classed  as  secondary  atrophy.  The  great  majority  of  so-called  cases 
of  infantile  atrophy  are  in  fact  cases  of  extreme  malnutrition  brought 
about  originally  by  improper  feeding  with  the  subsequent  development  of 
chronic  gastric  and  intestinal  indigestion.  Such  cases  may  present  clini- 
cally all  the  characteristics  of  the  severest  forms  of  primary  atrophy  but 
are  much  more  susceptible  to  treatment  either  by  breast  milk  or  by  care- 
fully modified  cow's  milk.  Clinically  it  is  often  impossible  to  separate  the 
primary  from  the  secondary  cases.     Slight  loss  of  weight  is  followed  by 


;U2  PEDIATrUCS. 

mild  indigestion,  which  in  turn  causes  more  loss  of  weight  and  a  kind  of 
vicious  circle  is  established  as  a  result  of  Avhich  all  grades  of  indigestion 
and  degrees  of  emaciation  may  develop. 

Infants  may  develop  the  disease  whose  food  is  seemingly  good  Inil 
whose  surroundings  in  crowded  cities  or  districts  are  unhygienic  as  to 
light,  Avarmth,  i)ure  air,  and  air  space.  On  the  other  hand,  the  disease  is  at 
times  met  with  in  the  country  where  the  hygiene  is  good  but  the  food  poor. 

Primary  atrophy  may  rarely  occur  in  breast-fed  infants,  Init  is  almost 
exclusively  found  in  those  who  have  been  on  the  bottle  since  birth,  and 
whose  milk  has  not  been  intelligently  modified  and  adapted  to  the  in- 
dividual requirements  of  the  child.  An  infant  may  be  given  at  birth  a 
milk  on  which  it  thrives  and  is  free  from  indigestion  lor  several  weeks, 
but  as  it  grows  older  it  requires  for  its  proper  nutrition  the  re-establish- 
ment, on  new  bases,  of  the  proportions  of  fats,  sugar  and  proteids,  and  if 
these  changes  are  neglected  and  if,  instead,  larger  quantities  of  the  original 
formula  are- given,  the  gain  in  weight  ceases,  then  loss  ensues  and  the  case 
may  pass  into  the  condition  of  atrophy  with  or  without  symptoms  of  indi- 
gestion as  the  case  may  be.  Autointoxication,  lack  in  cow's  milk  of  the 
digestive  ferments  supposed  to  exist  in  liuman  milk,  increased  fermenta- 
tion within  the  gastro-enteric  tract  with  absorption  of  the  decomposition 
products,  absence  or  diminution  of  certain  ferments  usually  present  in  the 
succus  entericus,  sub-acute  infections,  the  excess  of  volatile  fatty  acids,  es- 
pecially butyrin  in  cow's  milk,  all  these  and  many  more  have  been  ad- 
vanced as  causes  of  primary  infantile  atrophy,  but  in  the  light  of  our  pres- 
ent knowledge  we  cannot  assume  any  of  these  factors  to  be  proved  as 
fundamentally  responsible  for  the  disease.  Personally  we  are  of  the 
opinion  that  primary  infantile  atrophy  is  extremely  rare  in  infants  who 
are  fed  from  the  very  beginning  on  careful  modifications  of  cow's  milk  in- 
telligently adapted  to  the  infant's  nutritive  developuient. 

Pathological  Anatomy. — The  pathological  conditions  which  are  found 
in  cases  of  infantile  atrophy  are  exceedingly  unsatisfactory,  and  have  not 
"given  us  much  information  concerning  the  disease.  Nothing  abnormal  is 
found  in  the  various  organs  which  can  be  said  to  be  characteristic  of  this 
disease.  It  is  supposed  by  some  pathologists  that  the  lymph-glands  are 
enlarged,  but  this  enlargement  does  not  seem  to  be  a  prominent  feature, 
and  is  chiefly  confined  to  the  superficial  glands  of  the  neck,  axillae,  and 
groins.  No  pathological  condition  of  the  mesenteric  lymph-glands  has 
been  found,  and  the  atrophy  of  the  mesentery  around  them  is  so  great 
that  their  increase  in  size  may  be  more  seeming  than  real.  In  the  intes- 
tine, although  in  some  cases  there  is  considerable  atrophy  of  the  mucous 
membrane  and  the  submucous  tissue,  no  characteristic  lesion  has  been 
proved  to  be  present.  Therefore,  until  our  knowledge  of  the  pathology 
of  this  disease  becomes  more  defmite,  it  is  better  for  us  to  consider  its 
pathology  as  simply  atrophy.  Bloch  lays  great  stress  upon  the  absence 
of  granules  in  Paneth's  cells  in  Lieberkuhn's  glands  which  may  indicate  a 


DISEASES   OF   .NUTRITION.  34;3 

loss  of  some  element  of  the  succus  entericiis  which  would  cause  the  mal- 
nutrition. Certain  secondary  morbid  conditions  are  frequently  found. 
Prominent  among  these  are  concentration  of  the  blood,  high  haemoglobin, 
anaemia,  atelectasis  of  the  lungs,  bronchitis,  broncho-pneumonia,  fatty 
liver,  and  intestinal  catarrh. 

Symptom^. — The  essential  symptom  of  primary  infantile  atrophy  is  ex- 
treme wasting  which  usually  begins  in  the  first  two  or  three  months 
of  life  and  is  not  preceded  by  symptoms  of  indigestion  which  are  in  pro- 
portion to  the  degree  of  emaciation.  An  infant  which  has  perhaps  been 
weak  and  delicate,  or  may  have  been  seemingly  well  nourished,  begins  to 
emaciate.  The  prominent  feature  of  the  disease  is  tlie  progressive  and 
extreme  loss  of  weight  and  especially  of  the  subcutaneous  adipose  tissue. 
The  skin  is  dry  and  wrinkled,  and  hangs  in  folds  on  the  bones,  giving  the 
appearance  of  a  living  skeleton  or  advanced  old  age.  The  bones  of  the 
head  frequently  overlap  and  the  anterior  fontanelle  is  usually  depressed. 
The  extremities  are  cool.  The  abdomen  soon  becomes  sunken.  The 
tongue  is  dry  and  usually  reddened.  The  pulse  is  feeble  and  usually 
rapid.  The  temperature  is  normal,  or  more  commonly  subnormal, 
but  in  some  cases  is  raised.  The  respirations  are  generally  normal. 
Although  secondary  antemia  is  quite  a  prominent  condition,  extreme 
pallor  is  not  usual.  In  some  cases,  although  the  skin  is  pale,  the 
blood  count  shows  an  increase  in  haemoglobin  and  red  blood  corpus- 
cles, due  to  concentration  of  the  blood.  There  is  no  characteristic 
change  in  the  leucocytes.  The  appetite  is  usually  lessened,  but  may  be  at 
times  voracious.  In  many  cases  the  food  is  well  digested,  and  the  dis- 
charges yellow  and  smooth.  In  some  cases  the  total  amount  of  the  faecal 
discharges  in  twenty-four  hours  is  abnormally  large.  Regurgitation  of 
food  is  common,  and  at  times  vomiting  of  a  reflex  nature  becomes  promi- 
nent. The  normal  faecal  discharges  at  times  are  abnormal  in  color  and 
consistency.  In  advanced  cases  ecchymoses  may  appear  in  the  skin, 
sometimes  covering  the  entire  thorax  and  are  of  grave  significance,  but  do 
not  necessarily  indicate  a  fatal  termination. 

Diagnosis. — The  diagnosis  of  infantile  atrophy  is  chiefly  to  be  made 
from  ordinary  starvation  and  from  general  tuberculosis.  From  the  former 
it  is  soon  differentiated  by  its  lack  of  response  to  good  food  and  improved 
hygiene.  In  the  ordinary  cases  of  starvation  which  result  either  from 
improper  food,  or  from  lack  of  food,  a  diet  carefully  adapted  to  the  age  of 
the  infant  or  child  is  soon  followed  by  rapid  improvement.  The  cases  of 
wasting  from  mechanical  causes  are  recognized  by  detecting  the  special 
malformation  which  is  present.  Those  cases  which  are  secondary  to 
other  diseases  are  differentiated  from  the  primary  cases  of  infantile  atrophy 
by  the  prorninence  in  the  history  of  the  essential  symptoms  of  such  dis- 
eases. In  other  words,,  in  these  cases  the  wasting  is  not  the  one  essential 
symptom.  In  the  majority  of  cases  due  to  chronic  indigestion  from 
impro[)er  feeding,  the  symptoms  of  indigestion  antedate  the  loss  of  weight 


344  PEDIATRICS. 

and  the  extreme  wasting  comes  only  after  the  indigestion  has  persisted  for 
a  long  period.  When  symptoms  of  indigestion  have  appeared  early  in  the 
disease,  as  a  complication,  the  primary  form  cannot  be  separated  from  a 
secondary  atrophy  which  is  due  to  chronic  gastric  and  intestinal  indigestion. 
The  differential  diagnosis  from  general  tuberculosis  is  at  times  exceed- 
ingly difficult.  We  have  had  under  our  care  in  the  hospital,  in  adjacent 
beds,  an  infant  with  ir.fantile  atrophy  and  one  with  general  tuberculosis. 
In  these  two  cases  the  symptoms  and  courses  of  the  diseases  were  iden- 
tical, and  it  was  impossible  to  differentiate  the  two  diseases  except  at  the 
autopsy.  On  physical  examination  nothing  abnormal  could  be  found  in 
either  case  except  extreme  emaciation.  In  both  cases  the  temperature 
was  slightly  raised.  The  physical  examination  from  tuberculosis,  there- 
fore, if  the  temperature  is  raised,  is  almost  impossible,  as  complicating 
processes  in  the  lungs  may  produce  evidence  of  solidification  in  infantile 
atrophy.  When,  however,  solidification  is  prominent  in  the  front  of  the 
lungs,  the  cause  is  most  likely  to  be  tuberculosis.  The  presence  or  ab- 
sence of  the  tuberculin  reaction  will  in  many  cases  be  needed  to  differ- 
entiate the  two  diseases. 

Prognosis. — The  prognosis  of  primary  infantile  atrophy  is  bad,  espe- 
cially during  the  first  year  of  life.  Even  under  the  most  careful  treatment 
it  is  always  a  very  intractable  disease.  Even  the  most  exact  modification 
of  the  food  at  times  entirely  fails  to  cure  the  disease.  When,  however,  the 
infant  recovers,  the  recovery  is  usually  complete,  and  perhaps  within  a  year 
the  child  may  show  no  signs  of  the  previous  serious  condition.  The 
prognosis  in  the  secondary  forms  varies  with  the  nature  of  the  exciting 
cause.  The  longer  the  duration  before  careful  feeding  is  begun,  the  more 
difficult  it  is  to  restore  the  normal  functions  of  digestion  and  nutrition. 
We  have,  however,  repeatedly  seen  infants  of  six  or  seven  months  whose 
weight  was  practically  the  same  as  at  birth,  develop,  after  six  to  twelve 
months  of  careful  feeding,  into  average  healthy  babies.  The  prognosis  is 
unore  grave  in  the  cases  associated  with  severe  anaemia. 

Treatment. — The  treatment  of  infantile  atrophy  is  essentially  by  such 
modification  of  the  milk  as  to  promote  intestinal  absorption,  and  without 
drugs.  Especial  attention  should  be  paid  to  keeping  up  the  bodily  tempera- 
ture by  external  warmth  and  by  the  administration  of  stimulants.  Small 
doses  of  brandy  can  often  be  given  for  weeks  with  great  benefit.  It  is 
best,  when  possible,  to  provide  a  wet-nurse,  as  both  forms  of  atrophy 
respond  more  readily  to  good  breast-milk  than  to  any  other  food. 

Although,  as  has  already  been  stated,  it  is  not  entirely  proved  that  the 
morbid  condition  is  that  of  a  lack  of  absorption  or  assimilation,  yet  our 
clinical  results  are  most  favorable  when  the  disease  has  been  treated  on 
this  principle.  After  experimenting  in  a  large  number  of  cases  by  modi- 
fying the  different  constituents  of  the  milk  in  various  w^ays,  we  have 
arrived  at  the  following  conclusion :  a  mixture  should  be  given  which 
contains  a  low  percentage  of  fat,  a  high  percentage  of  sugar,  and  a  moderate 


DISEASES    OF   NUTRITION.  345 

percentage  of  proteids.  The  low  percentage  of  fat  is  given  on  the  suppo- 
sition that  the  infant  wiU  increase  in  Aveight  and  thrive  on  a  small 
proportion  of  fat,  provided  it  is  absorbed.  We  have  found  that  when 
higher  percentages  of  fat  are  given  the  infant  continues  to  lose  in  weight. 
The  administration  of  cod-liver  oil  is  not  indicated  in  these  cases,  for  it  is 
only  by  a  precise  adjustment  of  the  percentage  of  the  fat  in  the  food  to  the 
individual  power  of  absorption  that  good  results  can  be  obtained.  The 
sugar  of  high  percentage  and  the  proteids  of  normal  percentage  seem  to  be 
digested  and  absorbed  provided  they  are  combined  with  a  low  percentage 
of  fat,  since  by  this  combination  the  nutritive  properties  of  the  sugar  and 
of  the  proteids  are  made  use  of.  The  prescription  which  we  usually  write 
in  the  beginning  of  the  treatment  of  these  cases,  when  they  occur  in  the 
first  year  of  life,  is  the  following : 

Peescription  13. 

Fat : 0. 50 

Sugar 6.00 

Proteids  (whey  proteids  0.75,  caseinogen  0.25) 1.00 

Lime-water 5.00 

After  the  infant  has  begun  to  gain  in  weight  we  usually  increase  the 
percentage  of  the  fat,  but  for  a  number  of  weeks  we  do  not  raise  this  per- 
centage above  1  or  2.  When  the  above  formula  is  not  productive  of 
results,  we  sometimes  find  it  of  great  advantage  to  peptonize  for  fifteen 
minutes  before  each  feeding  the  milk  modified  as  above.  If  the  infant  is 
over  eight  or  nine  months  of  age  the  further  addition  of  barley-water  or 
jelly,  combined  with  the  peptonization,  will  often  prove  a  useful  measure. 
When  the  infant  has  once  begun  to  gain  steadily  the  power  of  absorbing 
fat  is  rapidly  regained,  and  percentages  such  as  are  in  the  following  pre- 
scription can  then  be  given  : 

Prescriptiox  14. 

Fat 3. 00 

Sugar 7. 00 

Proteids  (whey  proteids  0.75,  caseinogen  1.25) 2.00 

Lime-water 5.00 

The  same  treatment  can  be  carried  out  when  the  disease  occurs  in 
children  in  their  second  and  third  years,  but  in  these  cases  it  is  usually 
possible  to  increase  the  percentages  of  the  different  elements  more  rapidly, 
and  after  two  or  three  weeks  to  begin  with  other  articles  of  diet,  such  as 
beef-juice,  broths  of  various  kinds,  and  finally,  with  caution,  cereals.  Even 
in  these  cases,  it  is  sometimes  necessary  to  continue  the  modified  milk  for 
several  months  before  adding  other  varieties  of  food. 

These  special  modifications  of  the  milk  do  not,  of  course,  suit  every 
individual  infant  or  child,  and  when  the  treatment  with  them  is  not  suc- 
cessful, each  of  the  elements  of  the  milk  must  be  carefully  changed  and 
difi'erent  combinations  of  these  elements  tried  until  the  individual  idiosyn- 
crasy of  absorption  in  the  special  case  has  'been  discovered.     A  very  im- 


a-ili 


pEDIAi'KIt'S. 


portant  paj't  of  the  treatment  is  the  general  hygiene,  especiahy  sufficient 
air  space  and  pure  air. 

The  following  cases  illustrate  infantile  atrophy  of  high  grade. 

An  infant  nine  months  old  had  been  fed  on  foods  of  various  kinds,  all  of  which 
contained  a  considerable  percentage  of  starch.  She  is  said  to  have  been  healthy  and 
plump  at  birth  and  during  the  early  months  of  life  while  she  was  nursed.  After  she 
was  weaned  and  placed  on  starchy  foods  she  began  to  l«se  progressively  in  weight,  and 
became  extremely  emaciated.  Physical  examination  showed  nothing  abnormal.  She 
had  four  teeth.  Her  temperature  was  slightly  subnormal,  her  pulse  was  regular  but 
weak,  her  respirations  normal.      On  first  entering  the  hospital  the  bowels  were  consti- 


Infantile  atrophy.    Female.  9  months  old. 

pated  and  the  faecal  movements  were  brown  and  looked  poorly  digested.  On  being 
placed  on  a  diet  of  modified  milk  the  movements  became  well  digested  and  of  normal 
color,  but  the  total  amount  in  twenty-four  hours  was  greater  than  usual.  She  was 
very  fretful,  and  at  times  vomited,  but  when  her  diet  was  regulated  she  became  less 
fretful  and  somewhat  apathetic.  On  entering  the  hospital  she  weighed  2966  grammes 
(6J  pounds).  She  was  in  the  hospital  two  weeks,  and  gained  in  that  time  1000 
grammes.  The  food  which  was  found  to  suit  her  powers  of  absorption  contained  fat  1, 
sugar  5,  proteids  1,  lime-water  5.  and  60  to  120  c.c.  (2  to  4  ounces)  were  given  every 
two  hours. 

She  did  not  increase  progressively  in  weight,  ])ut  sometimes  lost  considerably,  and 
once  it  seemed  as  though  she  could  not  possibly  live.  After  the  food  had  been  modi- 
fied in  various  ways,  she  finally  began  to  improve,  and  when  she  was  able  to  digest 
and  absorb  150  c.c.  (5  ounces)  of  milk  so  modified  as  to  contain  fat  3.5,  sugar  6.5,  and 
proteids  1.5,  she  improved  rapidly,  and  eventually  recovered  entirely.  Her  tempera- 
ture, with  few  exceptions,  was  normal  or  subnormal  through  the  whole  course  of  the 
attack. 

FiQ.  92. 


Infantile  atrophy.    Female,  10  months  old. 
This  next  case  was  also  une  of  infantile  atrophy  of  high  grade.    Fig.  92. 
An  infant  10  months  old  entered  the  hospital  with  a  history  of  having  been  fed 
on  various  foods  containing  starch  from  the  earliest  months  of  its  life.     It  was  said 


DISEASES    OF    XUTKITIOX. 


341 


to  have  been  healthy  at  birth  and  of  average  weight.  On  entering  the  hospital  it 
weighed  2593  grammes  (of  pounds).  It  was  extremely  emaciated,  and  illustrated  the 
more  advanced  stage  of  infantile  atrophy.  It  was  unable  to  raise  its  head  and  was 
apathetic  ;  its  skin  was  cool  and  dry  ;  its  respirations  were  shallow  ;  its  pulse  was 
weak,  and  its  temperature  was  slightly  subnormal.  It  looked  as  though  it  could  not 
live  many  days.  A  physical  examination  showed  nothing  abnormal  in  any  of  the 
organs.  The  faecal  movements  were  rather  large  in  amount,  but  when  its  food  was 
carefully  regulated,  became  fairlj  well  digested.  On  entering  the  hospital  they  were 
still  larger  in  amount  and  were  of  a  brownish  color.  It  weighed,  after  being  in  the  hos- 
pital one  week,  2570  grammes  (about  5J  pounds),  which  was  slightly  less  than  its 
weight  on  entrance.  It  was  fed  on  a  modified  milk  in  which  the  percentage  of  fat  was 
2,  sugar  6,  proteids  1,  lime-water  10. 

In  two  weeks  the  infant  began  to  gain  in  weight  and  to  absorb  its  food.  Althou;i-h 
it  had  a  number  of  relapses,  in  which  it  lost  considerably  in  weight,  it  finally  began  to 
gain  steadily.  At  the  end  of  three  months  it  had  recovered  entirely,  and  was  quite 
plump.  In  this  case  the  percentage  of  the  fat  was  finally  raised  to  4,  and  that  of  the 
sugar  to  7,  but  the  proteids  had  to  be  kept  at  1  ;  the  lime-water  was  reduced  to  5. 

The  next  case  was  a  female,  one  and  a  half  years  old,  who,  on  entering  the  hos- 
pital, weighed  4281  grammes  (9J  pounds).  She  Vi'as  said  to  have  weighed  but  900 
grammes  (2  pounds)  at  birth.  She  was  nursed  by  her  mother,  who  apparently  had 
plenty  of  good  breast-milk,  and  who  had  two  other  children  whom  she  had  nursed 


Pig.  93. 


Infantile  atrophy.    Female,  IVo  years  old. 


thai  were  healthy  and  strong.  As  the  infant  did  not  gain,  she  was  nursed  for  only  a 
short  time,  and  was  then  fed  on  various  artificial  foods.  She  began  to  lose  in  weight. 
and  this  loss  continued  so  that  her  emaciation  was  extreme. 

On  physical  examination  the  anterior  fontanelle  was  found  to  be  widely  open. 
There  was  no  'enlargement  of  the  epiphyses  of  the  ankles  or  wrists,  but  there  was  a 
slight  rhachitic  rosary.  Nothing  abnormal  could  be  detected  in  any  of  the  organs.  She 
had  four  upper  and  two  lower  incisors.  She  Avas  very  apathetic,  and  seemed  hungry, 
but  when  food  was  given  to  her  she  vomited.  After  entering  the  hospital  she  lost  519 
grammes  (It  pounds)  in  two  weeks.  Her  skin  was  dry,  harsh,  and  at  times  quite 
cold.  The  fiscal  movements  were  very  large  in  amount,  but  after  entering  the  hos- 
pital were  fairly  digested.  The  cervical  and  inguinal  glands  were  slightly  enlarged  and 
she  had  a  slight  cough.  She  lost  steadily  in  weight,  did  not  respond  to  the  various 
modifications  of  the  milk  given  to  her,  and  died  three  weeks  after  entering  the  hospital. 

The  post-mortem  examination  showed  the   following  condition  :    There  was  ex- 


350  PEDIATRICS. 

Tlie  child,  two  and  a  half  years  old,  was  healthy  and  well  developed.  For  two 
weeks  it  had  been  very  irritable,  and  its  mother  brought  it  to  the  hospital  to  inquire 
about  an  efflorescence  which  had  appeared  on  its  skin.  On  investigating  the  lesions  a 
number  of  small  papules  and  a  few  pustules  scattered  irregularly  over  the  arms  and 
chest,  and  one  or  two  small  pustules  on  the  soles  of  the  feet  were  found.  The  fingers 
Avere  not  especially  affected,  but  in  one  or  two  places  at  the  base  of  the  fingers  the  efflo- 
rescence could  be  plainly  seen.  In  addition  to  the  papules  and  pustules  there  were 
numerous  lesions  of  the  skin  caused  by  scratching.  On  the  delicate  skin  of  the  abdomen 
was  a  minute  black  line  with  a  vesicle  at  one  end  of  it.  On  removing  carefully  with  a 
needle  a  little  of  the  fluid  in  this  vesicle  and  placing  it  under  the  microscope,  the  para- 
site, which  evidently  had  its  habitat  in  the  vesicle,  could  be  seen.  The  black  line  rep- 
resented the  burrow  by  which  it  enters  and  through  which  it  travels  as  far  as  the  vesi- 
cle, where  it  lodges  and  produces  irritation,  causing  first  a  minute  papule,  and  then  a 
minute  A^esicle.  Finally  the  vesicle  may  become  pustular.  In  this  case,  the  child's 
mother  showed  the  lesions  of  scabies  between  her  fingers. 

In  contradistinction  to  the  effects  of  the  Acarus  scabiei  on  the  skin  of 
adults  we  find  in  infants  and  young  children  that  the  parasite  may  attack 
the  soft  skin  of  the  soles  of  the  feet,  while  in  the  adult  we  do  not  find 
the  lesions  on  the  soles,  as  in  walking  the  skin  has  become  toughened  in 
that  locality.  In  adults  efflorescences  on  the  soles  of  the  feet  and  the 
palms  of  the  hands  are  rather  unusual  unless  they  are  connected  with 
syphilis  or  artificial  eczema.  Infants  and  young  children  are  usually  in- 
fected by  the  Acarus  scabiei  from  sleeping  in  the  bed  with  some  adult  who 
has  scabies. 

Treatment. — In  the  treatment  of  this  disease  it  is  very  important  to 
treat  it  in  the  mother  as  well  as  in  the  child.  The  clothes  of  the  bed,  of 
the  mother,  and  of  the  infant  should  first  be  thoroughly  steamed,  in  order 
to  kill  the  parasite,  and  it  should  be  impressed  upon  the  mother  that  the 
treatment  must  be  carried  out  very  carefully,  and  that  all  the  clothes 
which  have  come  in  contact  with  the  skin  must  be  thoroughly  cleansed. 

The  treatment  of  scabies  in  the  child  should  differ  somewhat  from  that 

which  is  employed  when  the  disease  occurs  in  the  adult,  because  the  skin 

~of  the  former  is  much  more  sensitive  than  that  of  the  latter.     The  severe 

remedies  which  can  properly  be  used  in  treating  the  adult  should  not 

be  employed  in  the  treatment  of  infants  and  young  children. 

A  simple  and  effective  ointment  recommended  by  Bowen  is  as  follows  : 

Pkescription  15. 
Metric.  Apothecary. 

Gramma. 
B   Balsami  Peruviani,  j  R    Balsami  Peruviani, 

Petrolati aa  60]  Petrolati aa  ^  ii. 

M.  M. 

For  older  infants  and  children  an  ointment  containing  sulphur  only 
may  be  employed  without  much  danger  of  irritating  the  skin,  or  sulphur 
may  be  combined  with  balsam  of  Peru  as  in  the  following  prescription  : 


DISEASES    OF   THE    SKIN.  3-^ 

Pkesckiptio.n   16. 

Metnc.  Ajiothecary. 
Gramma. 

R    Sulphuris  sublimati .  7:5  li    Sulphuris  sublimati jij  ; 

Balsami  Pei-uviani,  Balsami  Peruviani. 

Petrolati aa  3010  Petrolati aa    §  i. 

M.  M. 

Ill  the  use  of  either  of  these  ointments  the  following  technique  should 
be  employed.  The  child  is  to  be  first  thoroughly  washed  witli  warm 
water  and  soap.  The  skin  is  then  dried,  and  the  ointment  is  applied  over 
the  whole  body,  avoiding  the  head,  which  is  seldom  attacked  by  the 
parasite.  The  face  especially  might  be  irritated  by  the  ointment.  The 
ointment 'is  allowed  to  remain  on  the  child  during  the  night,  and  in  the 
morning  is  washed  off  with  warm  water  and  soap.  The  skin  is  then 
thorouglily  powdered  with  the  zinc  and  starch  powder  mentioned  on  page 
98.  This  treatment  is  contmued  for  three  or  four  days,  and  then,  if  the 
disease  is  not  entirely  cured,  it  can  be  repeated  for  a  few  days  more. 

A  certain  amount  of  eczema  is  usually  associated  with  scabies,  owing  to 
the  irritation  produced  by  scratching,  which  is  very  difficult  to  prevent. 
This  eczema  should  be  treated  by  soothing  applications  after  the  antipara- 
sitic treatment  has  been  completed. 

PEDICULOSIS. 
A  parasite  whose  nidus  is  on  the  head  appears  quite  frequently  in 
children  as  well  as  in  adults.  It  is  especially  met  with  among  the  poor 
and  ill  cared-for.  This  parasite,  i\\Q  pedicidus  capitis^  causes  extreme  irri- 
tation of  the  skin,  which  often  results  in  eczema  and  in  enlarged  lymph- 
nodes. 

Although  the  pediculus  itself  is  in  the  hair,  yet  by  its  irritating  action  on 
the  scalp  of  the  child  it  frequently  gives  rise  by  reflex  influence  to  patches 
of  eczema  grouped  about  the  nose  and  ears. 

Treatment. — In  treating  these  cases  the  hair  and  scalp  should  first  be 
saturated  with  petroleum.  This  application  is  allowed  to  remain  on  the 
head  for  several  hours,  and  later  is  thoroughly  washed  off  with  soap  and 
water.  The  nits  should  then  be  carefully  removed  by  means  of  a  fine 
comb  wet  with  vinegar.  It  is  usually  necessary  to  repeat  the  treatment 
for  two  or  three  days. 

IMPETIGO  CONTAGIOSA. 

Impetigo  contagiosa  is  a  disease  which  usually  occurs  in  children,  but 
it  may  be  found  in  adults.  It  sometimes  appears  as  an  epidemic,  and  in 
these  cases,  in  all  probabihty,  is  caused  by  the  same  micro-organism  as  in 
the  isolated  cases.  It  is  usually  met  with  among  the  poorly  cared-for,  but 
it  may  attack  the  healthy  as  well  as  the  sick  and  weak. 

Symptoms. — The  form  of  the  efflorescence  is  A'ariable.  Beginning  as 
small  vesicles,  the  lesions  soon  spread  over  a  larger  area,  coalesce,  usu- 
ally form  pustules,  and  later  become  rapidly  covered  with  a  thick  yellowish 
crust.  The  lesion  may  occur  on  any  part  of  the  body,  but  is  especially 
common  on  the  face  and  hands.     The  itching  is  very  slight  in  these  cases, 


354 


PEDIATRICS. 


Metric. 


Prescription  20. 
Gramma. 


Apothecary. 


B    Acidi  salicylici, 

Sulphuris 

Lanolini, , 

M. 


K 


;1a  3  75 
30  00 


Acidi  salicylici, 

Sulphuris 

Lanolini 

M. 


iui   ^  i 


It  should  he  applied  twice  daily,  and  should  be  thoroughly  rubbed  into 
the  bald  spots,  the  skin  first  having  been  washed  with  soap  and  water. 

When  the  ease  proves  to  be  somewhat  intractable,  still  stronger  appli- 
cations can  be  used,  and,  if  necessary,  a  certain  amount  of  carbolic  acid 

can  be  mixed  with  the  ointment,  from 
^i^-  ^5.  one-half  to  one  drachm  to  the  ounce  of 

ointment. 


Fig.  95  .  represents  a  boy,  eight  years  old, 
with  two  bald  spots  on  the  back  of  his  head. 
The  hair  over  the  rest  of  his  head  was  thick, 
and  there  were  no  appearances  of  loss  of  hair 
anywhere  else  on  his  scalp.  The  areas  of  scalp 
attacked  by  this  disease  vary  in  size.  In  this 
special  case,  however,  the  spots  were  about  2.5 
cm.  (1  inch)  in  diameter.  As  a  rule,  they  have 
a  fairly  regular  circumference.  On  examining 
the  spots  one  will  notice  that  there  are  little 
short  hairs  on  their  surfaces,  which  evidently 
have  broken  off  from  lack  of  nutrition.  On  the 
edges  of  the  spots  this  is  especially  noticeable. 
If  one  of  the  hairs  is  placed  under  the  micro- 
scope, one  will  find  a  specific  organism  which 
has  been  determined  to  be  the  cause  of  this 
It  is  of  vegetable  origin,  and  consists  of  masses  of  spores  composed  of  threads 


Tinea  tonsurans.    Male,  8  years  old. 


disease 

of  mycelium,  some  long  and  some  short,  which  are  divided  into  numerous  segments. 


TUJEA  FAVOSA. 

Tinea  favosa,  or  favus,  is  a  parasitic  disease.  Its  favorite  seat  is  the 
^ — scalp,  although  it  may  attack  any  part  of  the  body.  It  appears  in  the  form 
of  small,  bright  yellow,  cup-shaped  crusts,  which  upon  their  removal  leave 
a  permanent  but  superficial  cicatrix.  These  yellow  crusts  penetrate  the 
hair-follicle  and  destroy  the  growth  of  the  hair.  When  placed  under  the 
microscope  they  are  found  to  consist  almost  entirely  of  mycelium  and 
spores  of  the  form  called  Aohorion  schoenleinii.  The  crusts  often  become 
confluent,  forming  a  large  thick  covering  over  an  extensive  area. 

Treatment. — The  treatment  is  the  application  of  an  ointment  to  soften 
and  remove  the  crusts,  epilation,  and  anti-parasitic  ointments  such  as 
described  for  ringworm. 

TINEA  VERSICOLOR. 
This  is  a  very  rare  disease  in  children.    A  case  seven  and  a  half  years 
old  has  been  reported.    It  is  a  parasitic  disease  caused  by  the  microsporon 


DISEASES  OF  THE  SKIN.  355 

furfur.  The  lesions  consist  of  patches  of  fine  yellowish  scales,  usually 
situated  on  the  trunk.  There  are  no  subjective  symptoms.  Parasiticides 
combined  as  in  Prescription  16,  page  351,  remove  the  disease  very  quickly, 
but  it  is  prone  to  recur. 

ALOPECIA  AREATA. 

The  nature  of  the  disease  alopecia  areata  has  not  yet  been  determined. 
The  lesion  of  alopecia  areata  consists  of  an  irregular  surface  of  the  scalp 
entirely  free  from  hair  up  to  where  the  long  hair  begins  to  grow  on  it? 
edges.     The  appearance  of  the  skin  over  this  spot  is  normal. 

The  diagnosis  is  made  by  finding  a  bald  spot  on  the  head  having  the 
appearance  just  described.  The  remaining  part  of  the  scalp  is  found  to 
be  in  a  healthy  condition  and  well  covered  with  hair. 

Alopecia  areata  is  to  be  differentiated  especially  from  tinea  tricophytina. 
In  contradistinction  to  the  sound  and  healthy-looking  skin  of  the  former, 
we  find  in  the  latter  numerous  short  hairs,  which  are  broken  oif  through 
the  action  of  the  parasite. 

Alopecia  areata  is  somewhat  intractable  to  treatment  and  runs  a 
rather  long  course,  but,  as  a  rule,  in  children  can  be  cured. 

Treatment. — The  treatment  is  the  continual  application  of  stimulating 
remedies,  such  as  the  following  ointments  of  sulphur  and  tar : 


Prescriptio>'  21. 
Metric.  Apothecary. 

Gramma. 

R    Sulphuris 3 

Petrolati 30 


75    R  Sulphuris ?i ; 

00  Petrolati |i.' 


M.  M. 

Prescription  22. 
Metric.  Apothecary. 

Gramma. 

R   Olei  cadini 3175     R   Olei  cadini ^i  I 

Petrolati 30(00  Petrolati 51.' 

M.  M. 

These  remedies  should  be  used  so  as  to  produce  a  slight  rubefaction, 
but  not  inflammation. 

PEMPHIQUS  NEONATORUM. 

In  addition  to  the  true  pemphigus  of  adults,  the  pemphigus  which  is 
secondary  to  diseases  of  a  debilitating  nature,  and  the  epidemic  pemphigus 
infantilis,  we  at  times  meet  with  a  form  of  pemphigus  which  seems  to 
be  caused  by  a  parasite  of  the  skin.  These  cases  have  been  described  by 
Blomberg,  but  they  have  not  yet  been  fully  accepted  by  dermatologists, 
and  it  is  well  to  remember  that  on  the  delicate  skin  of  infants  and  young 
children  impetigo  contagiosa  may  cause  the  lesion  of  pemphigus  through 
the  activity  of  the  parasite  and  the  great  vulnerability  of  the  skin. 


35f;  .  PEDIATRICS. 


P3MPHIGUS. 


Pemphigus  is  a  disease  of  a  constitutional  character,  and  is  represented 
by  large  blebs  and  bullae.  It  occurs  at  times  in  infants  and  children  as  it 
does  in  adults,  but  is  very  rare.  There  is  a  form  of  pemphigus,  however, 
which  we  have  met  with  in  infants  and  children  in  which  bullae  of  various 
sizes  appear  upon  the  limbs  and  trunk,  and  which  is  not  connected  with 
sypliilis.  It  usually  occurs  in  poorly  nourished  children,  and  can  come 
not  only  as  a  disease  of  itself,  but  also  as  one  of  the  sequelse  of  debilita- 
ting diseases,  such  as  pneumonia,  rheumatism,  and  others.  AA'hen  it  is 
secondary  to  otlier  diseases  it  represents  a  condition  of  malnutrition,  and 
in  all  probability  is  not  connected  with  the  real  disease  pemphigus.  In 
my  expenence  this  class  of  cases  is  not  especially  serious,  but  merely 
represents  a  greater  or  less  degree  of  lack  of  vitality  of  the  skin. 

Tliis  form  of  pemphigus,  in  which  the  efflorescence  is  secondary  to 
other  diseases,  is  not  usually  seen  upon  the  soles  of  the  feet  or  in  the  palms 
of  the  hands,  and  tliis  is  of  considerable  aid  in  distinguishing  the  disease 
from  tlie  bullous  fonn  of  syphilis. 

Treatsiext. — There  is  no  especial  local  treatment  which  appears  to. 
benefit  this  condition  of  the  skin,  but  it  soon  disappears  when  the  general 
nutrition  of  the  cliild  has  again  become  normal  under  appropriate  feeding. 

EPIDEMIC    PEMPHIGUS    INEANTILJS. 

Where  pemphigus  occurs  as  an  epidemic  among  infants  in  foundling 
hospitals  it  is  of  a  more  serious  nature,  and  is  accompanied  by  constitu- 
tional symptoms,  represented  by  fever,  sometimes  lasting  from  three  to 
six  weeks.  In  these  cases  it  is  usually  acute,  but  it  may  become  chronic, 
and  last,  with  intervals  of  recurrence,  for  many  weeks  or  months.  These 
cases  are  more  apt  to  be  fatal  than  the  other  forms.  The  true  epidemic 
form  of  jjurident  ■pemphigus^  as  it  has  been  called,  is  almost  always  fatal, 
and  in  cases  in  which  it  is  not  secondary  to  any  other  disease  has  a  grave 
prognosis.  Many  of  the  reported  cases  of  this  epidemic  form,  as  well  as 
j^L  the  other  forms  of  pempliigus,  may  really  be  only  manifestations  of 
the  staphylococcus  invasion. 

DEBMATTTIS  EXFOLIATIVA  NEONATORUM  (Bitter's  Disease). 

In  the  year  1878  Ritter  gave  the  first  complete  description  of  the  dis- 
ease dermatitis  exfoliativa  neonatorum.  Previous  to  tliis  date  cases  of  this 
affection  had  been  reported,  but  many  of  them  were  regarded  as  some 
rare  or  unusual  manifestation  of  pemphigus.  Ritter  stucHed  and  reported 
the  cases  which  he  saw  at  the  Foundling  Asylum  in  Prague  from  1868  to 
1878.  A  careful  review  of  Hitters  original  observations  of  these  cases 
has  been  made  by  Elliot.  The  majority  of  cases  were  in  male  infants, 
and  the  mortality  was  found  to  be  48.82  per  cent.  The  disease  is  xevj 
rare.     It  occurred  rarelv  before  the  end  of  the  first  week,  and  usuallv 


DISEASES    OF   THE    SKLV.  357 

appeared  between  the  second  and  the  fifth  Aveek  of  life.  It  was  found  to 
vary  greatly  in  the  intensity  of  its  symptoms.  In  some  cases  a  dry  scaly 
condition.of  the  skin  preceded  tlie  subsequent  lesions,  which  had  ap- 
parently lasted  after  the  physiological  desquamation  of  the  epidermis  had 
taken  place. 

Symptoms. — ^The  first  symptom  noticeable  in  these  cases  was  a  diffuse 
redness,  usually  over  the  lower  half  of  the  face  about  the  mouth,  some- 
times, how^ever,  beginning  in  some  other  portion  of  the  body,  and  at  times 
being  universal  from  the  beginning.  This  hj^eraemia  of  the  skin  spread 
rapidly,  and  in  a  few  days  became  universal,  the  extremities,  as  a  rule, 
being  the  last  parts  affected.  The  mucous  membrane  of  the  mouth  and 
nose  was  at  times  affected,  and  the  conjunctivae  usually  participated  in  the 
hypergemia.  The  color  of  the  efflorescence  varied  from  a  light  to  a  dark 
purple-red.  As  the  hypersemia  extended  to  ne^v  surfaces,  those  wdiich 
were  first  affected  began  to  desquamate.  This  desquamation  at  times 
gave  no  evidence  of  exudation,  the  epidermis  being  simply  thickened,  and 
the  loosened  epithelium  separating  easily.  At  times  other  lesions  appeared, 
such  as  milia,  and  sometimes  the  homy  layer  of  the  skin  was  raised  above 
an  intensely  reddened  base,  and  large,  irregularly  shaped  bullae  filled  with 
fluid  were  formed.  After  the  desquamation  had  taken  place  the  skin  re- 
covered its  normal  condition,  occasionally  very  rapidly,  but  it  remained  for 
some  time  rough  and  irritable.  In  the  cases  in  which  there  was  no  exu- 
dation a  longer  time  was  necessary  for  the  separation  and  regeneration  of 
the  epithelium. 

Usually  the  disease  was  found  to  run  its  course  in  from  seven  to  ten 
days.  Relapses  were  sometimes  observed"  ten  or  twelve  days  after  the 
first  attack,  but  were  always  mild. 

In  typical  cases  the  process  was  unaccompanied  by  any  fever  or  sys- 
temic disturbances  unless  some  complication  existed.  The  functions  were 
normal,  and  the  weight  of  the  infant  remained  stationary  or  was  even  at 
times  increased.  The  fatal  cases  resulted  either  from  the  intensity  of  the 
attack  or  from  some  intercurrent  affection  or  sequela,  such  as  furunculosis. 
The  disease  is  usually  recognized  as  a  local  septic  infection  of  the  skin, 
and  it  would  seem  that  it  should  be  distinguished  from  the  pempliigus 
which  occurs  in  the  early  weeks  of  life. 

We  have  seen  but  one  case  in  which  it  seemed  that  this  diagnosis 
of  dermatitis  exfoliativa  could  reasonably  be  made. 

This  case  was  a  male  infant,  who  at  the  fourth  or  fifth  day  of  its  hfe  presented  a 
marked  condition  of  erythema  neonatorum.  After  a  few  days  this  erythema  began  to 
desquamate  slightly,  but  somewhat  later  a  pronounced  dermatitis  appeared  and  ran  its 
course  for  a  week.  During  the  course  of  the  disease  there  were  lesions  of  various  kinds 
represented  by  a  few  pustules  and  bullfe,  but  mostly  by  an  intense  erythema.  The 
lesions  gradually  grew  less  intense,  a  profuse  desquamation  took  place,  and  the  skin 
then  presented  a  normal  appearance.  During  the  course  of  the  disease  the  infant  did 
not  show  any  constitutional  symptoms,  and  gained  somewhat  in  weight.  The  parents 
were  healthy,  stronsr  people,  Avith  good  hygienic  surroundings. 


358  PEDIATRICS. 

DBBMATITIS. 

Dermatitis  is  an  inflammatory  afifection  of  the  skin,  produced  by  some 
recognized  cause.  The  lesions  are,  as  a  rule,  fugitive,  and  with  a  few  ex- 
ceptions are  not  characterized  by  an  especial  and  peculiar  form  of  efflo- 
rescence. The  course  of  the  disease,  and  the  recognition  of  some  definite 
exciting  cause,  enables  us  to  distinguish  tliis  condition  from  others  which 
resemble  it. 

Clinically  the  group  may  be  divided  into  a  dermatitis  traumatica,  de/ma^ 
Otis  venenata,  dermatitis  caloinca,  and  dermatitis  medicamentosa. 

Dermatitis  Traumatica. — Dermatitis  traumatica  is  the  term  applied 
to  the  local  reaction  which  takes  place  in  the  skin,  following  some  trauma, 
either  slight  or  severe,  such  as  may  result  from  pressure,  friction,  or 
direct  blows.  The  lesions  vary  from  a  simple,  temporary  erythema  to 
deep  and  extensive  ulcers,  as  in  certaui  bed-sores. 

Dermatitis  Venenata. — Dermatitis  venenata  is  the  name  applied  to 
those  dermal  lesions  which  are  caused  by  the  external  application  or  con- 
tact of  irritating  substances.  The  inflammatory  condition  may  be  due  to 
simple  mechanical  irritation,  such  as  is  sometimes  caused  by  the  lodgement 
in  the  skin  of  small  particles  of  matter ;  or  it  may  be  due  to  a  poison, 
arising  either  from  emanation  of  a  poisonous  volatile  principle  or. from 
actual  contact.  Ivy  poisoning  is  one  of  the  most  common  and  important 
examples  of  this  class  of  affections.  It  is  caused  by  contact  with  the 
leaves  of  the  rhus  toxicodendron.  The  cases  are  most  common  in  the 
autumn,  probably  owing  to  the  fact  that  people  are  tempted  to  gather 
the  leaves  because  of  their  brilliant  coloring  at  this  season  of  the  year. 
There  is  some  difference  of  opinion  as  to  the  volatility  of  the  poisonous 
active  principle.  Bhus  venenata,  or  poisonous  oak,  is  another  common 
cause  of  ivy  poisoning. 

Some  of  the  more  important  irritants  which  may  produce  a  dermatitis 
venenata  are  chrysarobin,  an  effective  remedy  in  psoriasis,  preparations  of 
carbolic  acid,  turpentine,  iodine,  mercury,  and  sinapis.  There  are  sixty  or 
^-^more  drugs  (White)  cited  as  more  or  less  frequent  causes  of  a  dermatitis. 
Kno^ving  the  great  delicacy  of  an  infant's  skin,  we  cannot  be  too  cautious 
in  prescribing  omtments  and  applications,  or  in  seeking  for  the  cause  of  a 
dermatitis  in  some  article  which  is  of  common  use  perhaps,  but  at  times 
an  undoubted  source  of  irritation  to  the  skin. 

Symptoms  of  Ivy  Poisoxixg. — The  eruption  appears  generally  within  a 
day  or  two  after  exposure,  ^dth  redness,  oedema,  and  papules,  wliich  pass 
rapidly  to  the  stage  of  vesicles,  which  may  become  pustular  from  a  second- 
ary infection.  The  course  of  the  chsease  is  from  two  to  six  weeks.  The 
face,  hands,  and  genitals  are  especially  hable  to  be  the  seat  of  the  disease, 
the  extension  to  other  parts  of  the  body  taking  place  by  means  of  the  hands. 

DiAGxosis. — The  lesions  of  ivy  poisoning  resemble  those  of  an  acute 
eczema.  In  making  the  diagnosis  especial  attention  should  be  paid  to  a 
history  of  exposure  to  ivy,  the  time  of  the  year,  the  asymmetry  in  the  dls- 


DISEASES   OF   THE   SKIN. 


359 


tributions  of  the  lesions,  and  the  history  of  previous  attacks,  and  especial 
susceptibility  will  often  aid  in  the  exclusion  of  other  similar  conditions,  es- 
pecially eczema. 

Treatment. — There  is  no  specific  remedy.  The  treatment  is  the  same 
as  in  an  acute  eczema,  except  that  it  is  well  to  begin-by  washing  the  skin 
thoroughly  with  soap  and  water.  Prescription  27.  page  365,  may  be  used 
as  a  wash,  and  some  simple  ointment,  as  Prescription  29,  page  366,  may 
be  applied. 

Dermatitis  Calorica. — Dermatitis  calorica  is  a  form  of  dermal  inflam- 
mation produced  by  the  milder  degrees  of  heat.  The  action  of  the  sun's 
rays  is  the  simplest  and  most  common  type  met  with  in  children.  The 
lesions  vary  from  a  simple  erythema  to  vesicles  and  bullae,  depending 
upon  the  intensity  of  the  heat,  the  duration  of  exposure,  and  the  suscep- 
tibility of  the  skin  in  an  individual  case.  Diminution  of  heat  may  pro- 
duce lesions  the  character  and  course  of  which  are  very  similar  to  those 
which  result  from  an  excess  of  heat.  Chilblains  are  a  common  example 
of  the  result  of  a  diminution  of  heat.  They  occur  chiefly  in  children 
with  feeble  circulation  who  wet  or  chill  their  feet,  and  suddenly  heat 
them.  In  such  instances  the  skin  is  red,  soft,  and  boggy.  The  boggy 
areas  may  break  down  and  form  indolent  ulcers,  which  dre  difficult  to  cure 

Treatment. — The  treatment  of  these  cases  of  dermatitis  calorica  is  the 
application  of  some  simple  lotion,  as  in  Prescription  24,  page  361,  or  of 
an  ointment,  as  in  Prescription  29,  page  366. 

Dermatitis  Medicamentosa. — Dermatitis  medicamentosa  is  a  general 
term  including  a  great  variety  of  lesions  produced  by  the  action  of  certain 

Fig.  96, 


Dermatitis  Medicamentosa  in  an  infant  of  eleven  months,  from  the  supposed  administration  of  fifty 
grains  of  bromide  of  potassium  in  the  course  of  three  days. 

drugs  administered  internally.     Arsenic  may  produce  an  efflorescence  of  a 
very  complex  character  which  may  be  erythematous,  papular,  urticarial, 


360  PEDIATRICS. 

bullous,  pustular,  and  even  hemorrhagic.  It  may  also  give  rise  to  a  herpes 
zoster,  as  a  result  of  certain  changes  in  the  nerve-endings.  Belladonna 
often  produces  an  efflorescence  of  an  erythematous  character  resembling 
closely  that  which  occurs  in  scarlet  fever.  The  iodides  are  especially  likely 
to  cause  an  efflorescence  of  acne.  The  bromides  often  cause  lesions  of  a 
papular  or  pustular  character.  Both  the  bromides  and  iodides  occasion- 
ally cause  lesions  of  a  most  unusual  character.  Chloral,  digitalis,  opium, 
quinine,  the  salicylates,  and  many  of  the  recent  new  remedies  sometimes 
cause  an  efflorescence.  The  erythematous,  urticarial,  and  papular  efflo- 
rescences which  are  seen  at  times  after  the  administration  of  antitoxin  will 
be  more  fully  described  under  diphtheria. 

Treatment. — The  treatment  consists  in  discovering  and  discontinuing 
the  drug  the  use  of  which  is  causing  the  irritation  of  the  skin. 

SUDAMINA. 

Sudamina  is  a  non-inflammatory  condition  of  the  skin  caused  by  occlu- 
sion of  the  ducts  of  the  sweat-glands.  The  lesion  is  represented  by 
minute  pearl-like  vesicles  occurring  on  the  skin  in  crops,  and  is  not  apt  to 
appear  in  febrile  conditions.  The  disease  is  of  no  significance  and  requires 
no  treatment. 

ERYTHEMA. 

Erythema  plays  an  important  part  in  the  diseases  of  infants  and  young 
children.  Although  it  is  one  of  the  most  common  and  readily  diagnosti- 
cated diseases  of  the  skin  which  occur  in  early  life,  yet  at  times  it  is  quite 
difficult  to  differentiate  it  from  other  diseases,  owing  to  the  variety  of  its 
forms.  It  may  be  divided  into  two  broad  classes  :  (1)  the  congestive  form, 
or  erythema  simplex.,  which  is  caused  by  traumatism  and  by  various  drugs, 
and  is  also  symptomatic  of  the  acute  exanthemata ;  (2)  the  inflammatory 
form,  erythema  multiforme,  which  may  affect  any  part  of  the  body  and 
either  small  or  large  surfaces.  It  has,  however,  a  predilection  for  the 
^ — backs  of  the  hands  and  of  the  feet.  Its  lesions  may  be  represented  by 
maculse,  or  in  the  process  of  its  evolution  these  maculae  may  develop  into 
maculo-papules,  vesico-papules,  papules,  vesicles,  and  even  bullae.  The 
lesions  vary  in  size.  The  color  varies  from  bright  red  to  purplish  red, 
and  is  sometimes  very  vivid.  The  delicate  texture  of  the  skin  of  young 
subjects  is  more  likely  to  show  variations  in  the  color  and  the  form  of  its 
lesions  than  is  the  fully  developed  and  stronger  skin  of  the  adult. 

Erythema  Simplex. — Symptoms. — The  symptoms  of  the  congestive 
form  are  varied,  and  they  do  not  accompany  each  manifestation  of  the 
disease  with  any  especial  regularity.  The  slightest  local  irritation,  whether 
from  parasites  or  trauma  of  any  kind,  changes  in  temperature,  reflex  irri- 
tation from  the  close  connection  between  the  digestive  organs  and  the 
skin,  and  many  other  reflex  manifestations,  may  produce  the  disease. 

Erythema  Multiforme. — Symptoms. — In   erythema  multiforme  there 


DISEASED    OF    THE    SKIX.  .'^^1 

may  be  pains  in  the  joints  simulating  rheumatism,  malaise,  slight  fever, 
nausea,  coated  tongue,  loss  of  appetite,  and  a  swollen,  tender  skm.  These 
more  marked  symptoms  are,  however,  often  absent,  and  the  lesions  of  an 
erythema  multiforme  commonly  appear  on  the  skm  of  young  subjects 
without  any  special  general  symptoms  accompanying  them.  It  is  better 
in  nursery  practice  not  to  endeavor  to  classify  tliis  protean  disease  under 
special  names  which  have  been  handed  down  from  time  immemorial  in 
the  text-books,  and  which  have  no  particular  significance.  They  have  been 
used  indefinitely  by  physicians,  and  the  same  form  of  lesion  is  sometimes 
called  by  one  name  and  sometmies  by  another. 

Treatmext. — The  treatment  of  all  forms  of  erythema  is  practically  the 
same.  It  consists  cliiefly  in  the  application  of  a  simple  poAvder  of  oxide 
of  zinc  and  starch,  and  of  a  lotion  consisting  of  either  lime-water  or  rose- 
water  m  wiiich  calamine  and  oxide  of  zinc  are  suspended. 


Prescriptiox  23. 
Metric.  Apothecary. 

Gramma. 

R   Zinci  osidi 7j5  R   Zinci  oxidi . . ?ii 

Amjli  tritici -. 60|o  Amyli  tritici 

M.  M.  " 

S. — For  external  application. 


n. 


Prescriptiox  24. 
Metric.  Apothecary. 


Gramma. 
R    Zinci  oxidi, 

Calaminaj  prseparatae aa       7 

Aquae  calcis 240 

M.  M. 

S. — For  external  application 


R   Zinci  oxidi, 

Calamine  praeparatas aa   3  ii ; 

0  Aqua?  calcis ^  viii. 


EBYTHBMA  rNTERTRIGO. 

This  is  a  conge?:tive  form  of  erythema.  It  is  represented  in  Plate  III., 
A,  opposite  pag-e  77.  This  form  of  erythema  is  that  which  occurs  in 
infants  in  the  folds  of  the  grom,  neck^  and  axillae.  The  lesion  has  already 
been  described  under  erythema  simplex.  Napkins  soaked  with  urine  and 
allowed  to  remain  for  some  time  without  being  changed  are  a  frequent 
cause  of  this  condition. 

The  treatment  is  to  keep  the  skin  clean  and  dry  by  the  application  of 
a  simple  powder.  No  soap  or  water  should  be  used  on  the  parts  affected, 
but  in  its  place  equal  parts  of  lime-water  and  water  can  be  used  for  wash- 
ing. One  of  the  most  effective  means  of  treating  intertrigo  is  by  the  use 
of  carron  oil  (equal  parts  of  lime-water  and  linseed  oil),  applying  it  with  a 
piece  of  cotton  after  each  change  of  the  diapers.  Applications  of  black 
wash  are  often  efficient. 

In  the  more  severe  forms  of  this  disease,  in  which  the  erythematous 
condition  has  become  eczematous,  and  where  the  skin  in  the  folds  of  the 
groins,  of  the  neck,  or  of  the  axillae  shows  fissures  and  the  moist  con- 


362  PEDIATRICS. 

dition  represented  by  eczema  madidans,  an  application  of  boracic  acid 
powder  is  efficacious. 

ERYTHEMA  NODOSUM. 
Another  form  of  erythema,  called  erythema  nodosum,  is  a  disease 
which  is  closely  allied  to  erythema  multiforme.     The  general  character- 
istics and  symptoms  of  erythema  nodosum  are  well  represented  in  the 
following  case : 

A  little  girl,  five  years  old,  was  perfectly  well  until  two  days  before  she  came  under 
observation.  At  that  time  she  began  to  have  loss  of  appetite,  fever,  and  malaise,  fol- 
lowed by  pain  in  both  her  legs.  Following  these  general  symptoms  an  efflorescence 
appeared  in  various  places  on  her  legs.  It  was  found  above  and  below  the  knees,  but 
mostly  over  the  tibiae  and  extending  down  as  far  as  the  ankles.  These  lesions  were  from 
1.2  to  2.5  cm.  (J  to  1  inch)  in  diameter,  and  were  of  a  somewhat  irregular  elliptical 
outline.  They  were  of  an  erythematous  type  and  had  a  delicate  pink  color.  The  skin 
over  the  lesions  was  hot  in  comparison  with  the  unaffected  portions  of  the  skin  around 
them.  The  lesions  were  tender  on  pressure,  and  their  tissues  were  somewhat  indurated, 
so  that  the  feeling  was  that  of  a  hard,  raised  swelling. 

The  disease  is  self-limited,  but  is  irregular  in  its  course.  It  usually 
disappears  in  about  two  weeks.  Its  cause  is  not  known.  The  treatment 
is  simply  palliative. 

ERYTHEMA    URTICATUM— URTICARIA. 

Nettle-Rash,  Hives. — The  term  urticaria  has  been  applied  to  an  efflo- 
rescence characterized,  as  a  rule,  by  wheals,  which  appear  suddenly  and 
disappear  quickly.  It  is  accompanied  by  intense  itching  and  burning,  and 
may  show  itself  on  any  part  of  the  skin,  in  lesions  either  small  or  largo 
in  number. 

It  is  commonly  caused  by  irritation  of  the  gastro-enteric  tract.  The 
disease  may  end  in  two  or  three  days,  but  usually  lasts  for  some  weeks, 
and  may  become  chronic ;  it  is  essentially,  however,  an  acute  affection. 

If  the  lesion  has  been  severe  there  may  be  slight  desquamation,  but 
this  is  rare.  Sometimes  there  may  be  only  one  attack ;  again  there  may 
be  relapses,  and  in  some  forms  and  in  certain  skins  it  may  occur  from 
year  to  year. 

When  seeking  for  the  cause  of  an  outbreak  of  urticaria  it  is  necessary 
to  investigate  carefully  as  to  whether  there  has  been  an  error  in  diet.  In 
children  some  simple  article  of  food  may  cause  an  urticaria  to  appear, 
just  as  in  some  adults  the  disease  occurs  from  an  idiosyncrasy  which  pro- 
hibits them  from  eating  oysters,  lobsters,  strawberries,  or  certain  other 
articles  of  diet.  Again,  in  some  individuals,  certain  drugs,  such  as  chloral, 
bromide  of  potash,  chlorate  of  potash,  and  belladonna,  may  cause  the 
dermal  lesions  of  urticaria.  The  wheals  of  urticaria  frequently  occur  as 
a  symptom  in  the  course  of  various  diseases,  such  as  scabies,  or  may  be 
caused  by  the  bites  of  insects. 

Treatment. — The  treatment  should  be  directed  first  to  the  removal  of 
the  cause  of  the  dermal  irritation.     When  this  cause  has  been  removed 


DISEASES    OF    THE    SKIX.  363 

the  dermal  lesions  ^dll,  as  a  rule,  disappear,  unless  still  further  irritation 

has  been  produced  by  scratching  the  lesion  or  by  its  being  too  severely 

treated  by  the  physician. 

The  diet  should  be  milk  for  a  time,  and  experiments  should  be  made 

with  different  articles  of  food  to  see  which  one  may  cause  this  especial 

form  of  irritation.     The  bowels  should  be  carefully  regulated.     The  local 

applications  consist  of  remedies  to  relieve  the  itclihig  and  burning,  in  the 

wearing  of  unirritating  clothing  and  soft  linen  next  the  skin,  and  in  a 

powder  of  starch  and  zinc,  made  as  described  on  page   361  frequently 

applied  to  the  lesions  at  intervals  during  the  day.     When  the  itching  is 

extreme,  anti-pruritic  lotions  and  ointments  should  be  used,  as  in  the 

following  prescriptions : 

Presckiption  25. 
Metric.  Apothecary. 

Gramma. 

B   Pulv.  calamine 715  R   Pulv.  calaminse gii; 

Aq.  calcis 240  0  Aq.  calcis ^  viii ; 

Acidi  carbolic! 187  Acidi  carbolic! ^  ss. 

M.  M. 

When  this  lotion  is  not  sufficient  to  allay  the  irritation  and  when  the 
burning  is  extreme,  the  following  ointment  can  be  applied : 

Presceiptiox  26. 
Metric.  Apothecary. 

Gramma. 

R   Menthol O'e  R   Menthol gr.  x  ; 

Adipis 3010  Adipis gi. 

M.  M. 

ECZEMA. 

Eczema  is  a  disease  of  the  skin  which  plays  a  much  greater  role  in 
infancy  and  early  childhood  than  in  any  other  period  of  life.  It  is  often 
very  difficult  to  cure.  Even  in  the  milder  forms  of  the  disease  we  should 
be  cautious  about  giving  too  favorable  a  prognosis  at  first,  for  the  disease 
may  extend  and  involve  new  areas  of  skin. 

Pathological  Anatomy. — The  pathological  changes  which  occur  have 
been  designated  by  certain  descriptive  names,  such  as  eczema  erythematosuin, 
generally  secondary  to  other  lesions  ;  eczema  jiapidosum.,  which  may  be  a 
terminal  or  merely  secondary  stage  of  the  process ;  eczema  vesiculosum^  which 
is  never  primary,  but  is  preceded  by  a  papular  stage,  and  may  end  as  such 
or  pass  on  to  the  more  advanced  lesions  ;  eczema  macJidans,  or  "weeping 
eczema, "'  in  which  the  vesicles  form  large  blisters  containing  sero-purulent 
or  sero-hemorriiagic  contents  which  exude  and  form  crusts  ;  eczema  jjustu- 
losiim,  which  may  begin  as  a  primary  lesion  or  develop  secondarily  to  the 
vesicular  or  madidans  stage  ;  and,  finally,  eczema  squamosum,  which  is  never 
primary,  but  represents  the  final  stage  of  the  pathological  process  in  which 
the  epidermal  scales  are  thrown  off,  leaving  exposed  a  dry,  itchy,  reddened 
skin.  After  resolution,  cicatrices  rarely  occur,  unless  from  severe  secondary 
changes. 


;364  PEDIATRICS. 

Symptoms. — Clinically  the  disease  may  be  divided  into  the  acute  form, 
characterized  by  a  sudden  onset,  short  course,  and  frequent  recurrence  of 
any  of  the  pathological  conditions  just  mentioned ;  and  by  the  chronic 
form,  which  represents  the  more  characteristic  lesions  of  cell  infiltration 
and  tliickening  of  the  skin,  scaling,  fissures,  and  ulcers.  The  disease  may 
begin  as  an  acute  or  as  a  chronic  process,  starting  as  an  erythema  or  as 
isolated  and  grouped  papules,  vesicles  or  pustules,  either  singly,  simul- 
taneously, or  in  succession,  resulting  in  redness,  oozing,  scaling,  crusting, 
and  infiltration.  The  intense  itching  and  burning,  A^ithout  tenderness,  are 
the  important  and  characteristic  points  serving  to  distinguish  the  condition 
from  a  dermatitis.  Tlie  disease  may  be  divided  into  two  types,  regional  or 
local  eczema  and  universal  eczema. 

Regional  Eczema. — ^The  most  common  form  of  regional  eczema  oc- 
curring in  infants  and  young  children  is  localized  on  the  face,  and  com- 
monly extends  to  the  necTc.  This  form  is  especially  distinctive  of  infancy, 
and  is  frequently  \erj  intractable.  No  one  form  of  treatment  or  kind  of 
application  benefits  every  case,  but  one  remedy  after  another  may  have 
to  be  tried.  As  the  infant  grows  older  this  form  of  eczema  passes  away 
of  itself  and  is  not  apt  to  return. 

Many  instances  of  local  eczema  produced  by  some  irritation  at  or  near 
the  place  affected,  or  perhaps  in  an  entirely  different  part  of  the  body,  are 
met  ^\'ith  m  children.  This  is  usually  called  reflex  eczema,  an  example  of 
which  may  be  found  in  the  irritation  of  the  scalp,  such  as  occurs  from 
pediculi.  from  which  a  local  reflex  eczema  may  develop  on  the  back  of  the 
neck. 

Other  varieties  of  regional  eczema  are  limited  to  the  eyes,  giving  rise  to 
swelling,  pustules,  furuncles,  and  conjunctivitis,  a  condition  which  may 
easily  be  mistaken  for  erysipelas,  but  shows  no  tenderness  and  itches 
badly.  The  ears,  genitals,  legs.  fed.  and  hands  may  all  be  the  site  of 
eczematous  lesions. 

Universal  Eczema. — Attacks  of  universal  eczema  may  occur  in  chil- 
dren as  they  do  in  adults,  and  are  often  very  intractable.  The  lesions  are 
essentially  the  same  as  in  regional  eczema,  but  differ  in  that  ihey  are  more 
universally  distributed. 

Treatment. — The  importance  of  the  treatment  of  eczema  does  not  de- 
pend so  much  on  any  particular  ointment  or  drug  as  on  the  method  of 
applying  the  remedy.  The  principal  mdication  is  to  keep  the  child  quiet 
and  the  skin  free  from  the  irritation  of  scratching,  thus  allowing  it  to 
recover  its  \itality.  At  times  it  is  necessary  to  strap  the  child  on  its  back 
in  bed  and  to  have  a  nurse  in  constant  attendance  until  the  more  irritable 
stage  of  the  disease  has  passed  off.  Scratching  the  lesions  even  for  a  few 
moments  may  retard  the  recovery  for  many  weeks. 

If  necessary  in  the  early  hours  drugs  of  a  soothing  nature  may  be 
given  to  prevent  undue  nervous  symptoms.  The  nurse  should  be  gentle, 
and  should  endeavor  continually  to  divert  the  child's  mind.     The  treat- 


DISEASES    OF    THE    SKL\. 


365 


ment  consists,  then,  first  in  allaying  the  itching  by  local  applications,  and 
of  so  covering  the  part  affected  that  scratching  is  impossible.  It  is  of; en 
necessary  to  pin  the  sleeves  of  the  dress  to  the  napkin  or  to  immobilize  the 
elbow  joint  by  light  splints,  made  of  card-board,  so  that  the  hands  cannot 
reach  any  exposed  surface.  The  discomfort  from  the  restraint  will  soon 
pass  away,  and  the  method  of  treatment  is  not  cruel.  Certain  general 
precautions  should  be  observed.  Heat  and  excess  of  cold  should  be 
avoided,  and  the  clothing  should  be  thin  and  as  non-irritating  as  possible. 
The  physical  condition  of  the  child  should  be  carefully  investigated  in 
regard  to  the  urine,  blood,  bowels,  appetite  and  nutrition,  and  appropriate 
symptomatic  treatment  should  be  given. 

Drugs. — Drugs  may  be  administered  as  washes,  powders,  and  oint- 
ments, but  never  as  tinctures,  in  the  acute  forms  of  eczema.  Water  should 
never  be  used  in  the  treatment  of  acute  eczema.  The  list  of  drugs  is  long, 
and  only  a  few  of  the  more  important  ones  need  be  mentioned.  A  sim- 
ple powder  of  starch  and  zinc  oxide,  such  as  is  given  on  page  361,  will  be 
found  most  useful  on  moist  surfaces.  In  all  acute  cases,  and  as  an  anti- 
pruritic, the  follo^^ang  prescription  will  be  found  of  value. 

Prescriptiox  27. 

Apothecary. 


Metric. 

Gramma 

R   Zinci  oxidi 15  00 

Glycerini 3|7o 

Acid,  carbol l'88 

Aq.  calcis q.s.  ad  240  00 

M. 


R    Zinci  oxidi ^  ss  ; 

Glycerini ^  i ; 

Acidi  carbolici  (xtals) 3  ss  : 

Aqu»  calcis q.s.  ad  ^  "^'i"- 

M. 


Calamine  may  be  used  in  the  above  prescription  in  place  of  the  oxide 
of  zinc,  as  in  Prescription  25,  on  page  363,  and  it  is  often  desirable  tu  add 


Fig.  97. 


Eczema  capitis. 


60  c.c.  (2  ounces)  of  camphor- water  to  replace  an  equal  quantity  of  lime- 
water.     Another  ointment^  whir-h  we  usp  extensivelv.  is  made  bv  mixins 


366 


PEDIATRICS. 


one  ounce  of  bismuth  subnitrate  with  one  ounce  of  agnine,  and  then 
thinning  it  out  with  two  ounces  of  hnie-water.  An  ointment  of  sulphur 
and  oxide  of  zinc,  1.88  grammes  (|  drachm)  of  each  to  30  grammes  (1 
ounce)  of  vaseline,  is  very  useful  in  eczema  of  the  scalp,  or  the  bismuth 
ointment  is  equally  efficacious. 

In  the  treatment  of  the  dry,  scaling,  infiltrated  form  of  chronic  eczema, 
when  there  are  no  excoriations  or  acute  lesions,  the  following  prescription 
of  White's  may  be  used. 

PRESCRIPTIOJf   28. 


Metric. 

Gramma. 

R  Sapo  viridis,  I 

Alcohol    aa  60 

rilter  and  add 

Oieicadini 15-30 

M. 


Apothecary. 

Sapo  viridis, 

Alcohol aa   ^  ij  ; 

Filter  and  add 

Olei  cadini g ss-j. 

M. 


In  very  severe  forms  of  chronic  eczema  which  do  not  yield  to  local 
treatment,  one  should  try,  with  caution,  the  effect  of  the  small  doses  of 
Fowler's  solution.  It  is  occasionally  an  effective  adjunct  to  local  applica- 
tions. 

Fig.  97  represents  a  case  of  eczema  of  the  scalp  and  face  which  illus- 
trates the  disease  very  well. 


They  consisted  of  papules,  pus- 


FiQ.  98. 


The  lesions  were  confined  to  the  head  and  face. 
tules,  crusts,  some  excoriated  patches  caused  by 
scratching,  and  a  thick,  rather  oedematous  con- 
dition of  the  skin,  especially  around  the  lips, 
nose,  and  eyes.  The  hair  was  cut  off,  and 
various  lesions  were  found  on  the  scalp  ;  in  cer- 
tain parts  of  the  scalp  a  reddened  moist  con- 
dition, called  eczema  rubrum,  was  found. 


The  treatment  was  as  follows  :  the  crusts 
and  the  thickened  tissue  of  the  face  and  scalp 
were  first  softened  by  means  of  a  poultice.  After 
the  larger  crusts  had  been  removed,  a  mask,  as 
shown  in  Fig.  98,  was  applied  to  the  face  and 
scalp.    The  inner  surface  of  this  mask  was  thickly  spread  with  the  following  oinimem  ; 


Method  of  treating  eczema  capitis . 


Metric. 

R  Unguenti  zinci  oxidi, 

Lanolini 

M. 


Apothecary. 


Prescription  29. 

Gramma. 

I             R  TJnguenti  zinci  oxidi, 
.aa  30jOO  Lanolini 


.  aa   ^  J, 


An  interesting  complication  of  universal  eczema  which  may  at  times 
arise  is  illustrated  in  the  following  case  : 


A  girl  came  to  the  hospital  to  be  treated  for  torticollis.  The  head  was  drawn  to 
the  left  side  and  she  could  not  straighten  it.  This  condition  had  lasted  for  many 
months. 


DISEASES   OF   THE   SKIN.  367 

On  examining  the  child  we  found  that  she  had  the  usual  universal  eczema  of  a 
chronic  type  affecting  the  head,  face,  and  extremities.  On  examining  the  neck  we 
found  a  number  of  enlarged  tender  lymph-nodes.  These  enlarged  nodes  were  evidently 
caused  by  reflex  irritation  from  the  eczema,  and  were  the  cause  of  the  torticollis. 

She  was  treated  with  the  zinc  oxide  ointment  (Prescription  29)  and  the  usual 
bandage  and  mask,  and  in  a  short  time,  alVaough  the  eczema  was  not  entirely  cured, 
the  irritation  in  connection  with  it  had  been  so  much  lessened  that  the  glands  of  the 
neck  gradually  subsided  and  disappeared,  and  the  child  was  able  to  hold  her  head 
straight. 

We  are  often  asked  whether  the  eczema  of  infants  is  contagious.  We 
have  seen  instances  where  the  nurse  Avho  was  taking  care  of  a  case  of  eczema 
developed  the  disease  on  her  hands.  The  lesions  were,  however,  ap- 
parently caused  by  washing  the  infant's  napkins,  as  her  hands  were  cured 
by  local  treatment,  and  the  subsequent  use  of  rubber  gloves  while  washing 
the  napkins  prevented  her  from  again  contracting  the  disease.  Cases  of 
this  kind  give  rise  to  the  idea  that  eczema  is  contagious,  but  the  proba- 
bility is  that  they  are  simply  cases  of  artificial  dermatitis  caused  by  irri- 
tating substances  of  various  kinds,  and  that  there  is  no  especial  germ 
which  causes  eczema.  We  can,  therefore,  say  that  the  disease  is  not  con- 
tagious, and  that  simple  cleanliness  and  protection  of  the  hands  by  means 
of  rubber  gloves  are  all  that  is  necessary  to  prevent  the  disease  being 
contracted. 

PSORIASIS. 

Nothing  is  known  of  the  real  cause  of  psoriasis.  So  far  as  we  can 
ascertain,  it  is  not  dependent  on  any  micro-organism.  When  the  disease 
is  well  developed  the  diagnosis  is  very  simple,  and  its  lesions  correspond, 
as  a  rule,  to  those  which  are  commonly  met  with  in  the  adult.  It  begins 
with  small  papules,  which  almost  immediately  become  covered  with  scales. 
These  scales  have  a  pearly  white  color,  and  on  removing  them  we  find  a 
bleeding  surface,  showing  that  they  are  more  closely  connected  with  the 
corium  than  is  the  case  in  other  diseases  in  which  desquamation  takes 
place,  such  as  dermatitis  or  scarlet  fever. 

The  efflorescence  of  psoriasis  is  general,  and  is,  as  a  rule,  marked  on 
the  elbows  and  knees,  for  in  these  places  the  lesions  coalesce  and  the 
scales  are  especially  thick. 

We  have  noticed  in  the  psoriasis  of  children  that  the  type  of  the  disease 
is  often  so  mild  that  we  can  scarcely  believe  we  are  dealing  with  the  same 
affection  that  we  are  accustomed  to  see  in  the  adult.  In  some  cases  a 
few  lesions  scattered  here  and  there,  especially  on  the  back  over  the  scap- 
ulae, will  be  all  that  represent  the  disease,  and  are  easily  cured,  even  dis- 
appearing of  themselves  in  a  few  months.  Besides  affecting  the  trunk 
and  extremities,  the  efflorescence  may  occur  on  the  scalp,  especially  along 
the  edge  of  the  hair  on  the  forehead,  but  the  disease  is  not  very  common 
on  the  face,     Psoriasis  is  apt  to  recur  even  at  intervals  of  years,  so  that 


.S6S  PEDIATRICS- 

we  cannot  say  that  it  can  be  absolutely  cured,  although  at  times  it  may 
disappear  under  treatment  and  never  return. 

Treatment. — The  treatment  of  psoriasis  in  children  should  be  milder 
in  form  than  that  employed  in  treating  the  adult.  In  the  above  case  an 
ointment  of  chrysarobin  applied  to  the  lesions  in  the  evening  and  washed 
off  with  soap  and  water  in  the  morning  was  used,  there  being  no  treat- 
ment during  the  day. 

Prescription  30. 
Metric.  Apothecary 


Gramma. 

R    Chrysarobini 0 

Petrolati   30 


60         R    Chrysarobini gr-  x  ; 

00  Petrolati 5  i. 


M.  M. 

This  ointment  stains  the  skin,  but  not  permanently.  It  should  never 
be  applied  to  the  face  or  the  scalp,  and  should  be  used  with  great  care,  as 
it  causes  on  some  skins  considerable  irritation,  and  at  times  a  severe  der- 
matitis.    With  ordinary  caution,  however,  this  need  not  occur. 

In  intractable  cases  in  which  this  milder  form  of  ointment  is  not  effi- 
cacious, the  strength  may  be  increased  to  1  or  1.5  grammes  (15  or  20 
grains)  to  the  ounce. 

It  should  be  remembered  that  chrysarobin  stains  the  clothes  black  in- 
delibly, so  that  old  sheets  and  night  apparel  should  be  used  while  the 
treatment  is  being  carried  out. 

In  place  of  this  ointment  one  can  use  on  especially  irritable  skins,  or 
on  the  face  and  scalp,  the  following  prescription  of  sulphur  and  tar  : 

Prescription  31. 

Metric.  Apothecary. 
Gramma. 

R     Sulphuris 3|75  R     Sulphuris 3  i  J 

Olei  cadini 187  Olei  cadini 3  ss  ; 

\clipis               30I0O  Adipis .1  i. 

M.  M. 

Intractable  cases  may  sometimes  be  cui-ed  by  producing  an  artificial 
dermatitis  by  means  of  exposure  to  the  rays  of  sun-light.  A  similar  effect 
is  produced  by  repeated  exposure  to  X-rays. 

PRURIGO. 

Prurigo  occurs  in  two  forms  in  infants  and  children,— (1)  'prurigo  mitis 
infantilis  and  {2)  prurigo  fer ox. 

(1)  Prurigo  Mitis  Infantilis. — Prurigo  mitis  infantilis  occurs  in  infants 
two  or  three  months  old,  and  may  last  for  some  years.  It  is  closely  allied 
to  papular  erythema,  but  is  more  chronic  and  has  a  greater  tendency  to 
recur.     It  is  very  rare  in  America. 

Symptoms.— It  begins  with  little  nodular  infiltrations,  especially  marked 
on  Ihe  anterior  surface  of  the  extremities,  and  is  accompanied  by  great 


DISEASES    OF    THE    SKIN.  3g9 

itching.  It  may  appear  on  the  face.  It  does  not  lead  to  an  infiltration  of 
the  skin  or  to  the  formation  of  pus. 

Treatment. — The  treatment  consists  in  remedies  to  relieve  the  itching 
and  allay  the  eczema  with  which  it  is  usually  complicated. 

(2)  Prurigo  Perox. — Instead  of  this  mild  form  a  more  severe  type  of 
prurigo  occurs  at  times.  This  latter  form  is  far  more  serious  in  its  symp- 
toms and  in  its  prognosis,  and  may  continue  through  life.  The  disease, 
which  is  characterized  by  the  same  dermal  lesion  as  that  just  described,  is 
progressive  from  the  beginning ;  it  usually  starts  on  the  legs,  and  the  skin 
becomes  thicker  as  it  descends.  The  efflorescence  is  accompanied  by 
enlarged  glands,  especially  in  the  inguinal  region. 

The  disease  is  rare  in  America,  but  is  common  in  Germany. 

Its  etiology  is  very  obscure,  and  it  is  a  most  intractable  chronic 
affection. 

Treatment. — The  treatment  is  palliative. 

For  the  extreme  itching  caused  by  the  papules  an  application  of  the 
following  ointment  may  be  used : 

Prescription  32. 

Metric.  Apothecary. 

Gramma. 


li   Unguenti  diachyli, 

Petrolei aa  30 


R    Unguenti  diachyli. 

»  00  Petrolei aa  g  i. 

M.  M. 

S. — To  be  applied  on  flannel  three  times  a  day  for  ten  minutes,  and  to  be  followed  by 
the  application  of  this  ointment : 

Prescription  33. 
Metric.  Apothecary. 

Gramma. 
R   Unguenti  diachyli,  j         R   Unguenti  diachyli, 

Petrolati aa  SOJOO  Petrolaii aa  §  i. 

M.  M. 

If  there  is  much  infiltration,  sapo  viridis  should  be  applied  at  night 
and  washed  off  the  next  morning.  It  must,  however,  be  used  with 
caution,  as  it  is  very  irritating. 

HERPES  ZOSTER. 

Herpes  zoster  is  a  disease  which  affects  both  children  and  adults.  The 
cause  of  the  disease  has  not  as  yet  been  determined,  but  it  is  a  condition 
closely  connected  with  the  nerves. 

Symptoms. — The  general  symptoms  of  herpes  zoster  are  fever,  loss  of 
appetite,  and  pain  in  some  part  of  the  head,  trunk,  or  extremities.  The 
pain  is  always  located  in  the  course  of  certain  nerves.  In  some  cases, 
however,  the  pain  and  constitutional  symptoms  are  absent. 

One  of  the  characteristics  of  the  efflorescence  is  that,  as  a  rule,  it  is 
unilateral.  It  is  extremely  rare  for  the  affection  to  be  bilateral  and  to  ex- 
tend around  the  body.  Cases  of  this  kind,  however,  have  occurred,  and 
do  not  seem  to  be  any  more  severe,  except  that  larger  surfaces  are  affected, 

24 


370  PEDIATRICS. 

than  where  the  affection  is  unilateral.  The  character  of  the  efflorescence 
is  essentially  vesicular,  and  is  to  be  differentiated  from  varicella,  which 
might  be  accompanied  by  the  same  general  symptoms  and  is  also  essen- 
tially a  vesicular  disease.  The  efflorescence  of  varicella  is  general,  is  not 
limited  to  any  special  distribution  of  the  nerves,  nor  is  it  painful,  while  the 
efflorescence  of  herpes  zoster  is  limited  to  the  distribution  of  a  special  set 
of  nerves.  The  vesicles  become  somewhat  pustular,  and  soon  crusts  are 
formed. 

The  disease  runs  a  definite  course  of  about  fourteen  days,  and  from 
the  beginning  is  accompanied  by  considerable  pain,  although  according  to 
our  observations  the  pain  is  not  so  severe  in  children  as  in  adults,  nor  is 
the  itching  so  annoying. 

Fig.  99. 


Showing-  the  lesions  of  herpes  zoster  in  a  girl  of  4  years. 

Diagnosis. — The  diagnosis  of  this  disease  is  very  easily  made  from 
the  general  symptoms  of  pain,  fever,  and  malaise,  in  combination  with 
the  characteristic  efflorescence,  and  we  at  once  know  with  what  disease 
we  are  dealing,  for  no  other  affection  of  the  skin  has  so  definite  a  distri- 
bution. 

Prognosis. — The  disease  is  usually  benign  in  children,  but  the  case  of 
a  child  four  years  old  who  died  during  an  attack  of  herpes  zoster  without 
other  assignable  cause  has  been  reported. 

Treatment. — The  treatment  is  simply  palliative.  What  we  are  accus- 
tomed to  do  is  to  regulate  carefully  the  child's  diet,  as  we  would  in  any 


DISEASES   OF   THE    SKIN.  371 

disease  with  general  constitutional  symptoms,  and  to  endeavor  by  the 
application  of  lotions  to  allay  the  pain.  Sometimes  merely  a  simple 
powder,  such  as  the  prescription  on  page  361,  is  sufficient  to  allay  the 
local  symptoms. 

PITYRIASIS. 

Pityriasis  is  a  term  that  is  now,  like  the  word  lichen,  seldom  used 
without  an  accompanying  adjective.  There  are  two  recognized  forms  of 
the  affection. 

(1)  Pityriasis  Rubra  is  a  rare  disease  in  children,  characterized  by 
hypersemia  and  fine  scales  affecting,  as  a  rule,  the  whole  cutaneous  sur- 
face. It  may  be  attended  with  great  constitutional  disturbance  and  lead 
to  death.     Its  duration  is  always  uncertain. 

(2)  Pityriasis  Maculata  et  Circinata,  or  Pityriasis  Rosea,  affects  chil- 
dren as  well  as  adults.  It  appears  in  the  form  of  small  patches  of  scales 
scattered  over  the  trunk,  legs,  and  arms.  These  patches  either  spread 
peripherally  or  unite  to  form  larger  patches  while  the  centre  undergoes 
involution ;  we  thus  see  a  reddish  scaling  border  and  a  characteristic  yel- 
lowish centre.  There  may  or  may  not  be  great  pruritis  accompanying  it. 
In  Vienna  this  affection  is  still  regarded  as  a  form  of  ringworm,  a  posi- 
tion that  cannot,  however,  be  maintained.  Its  etiology  is  obscure.  It  gets 
well  spontaneously  in  from  two  to  ten  weeks,  and  is  best  treated  by  mild, 
soothing,  and  anti-parasitic  applications. 

VERRUCA. 
Verrucas  (warts)  are  circumscribed  outgrowths  of  the  papillae  of  the 
skin  with  an  accompanying  increase  in  the  thickness  of  the  epidermic 
layers.  They  are  common  in  children,  especially  on  the  hands,  and  the 
old  view  that  they  are  contagious  and  auto-inoculable  has  gained  many 
adherents  of  late.  They  are  of  various  aspects  and  shapes,  and  may  be 
treated  locally,  as  a  rule,  with  success,  although  some  are  quite  obstinate. 
The  most  efficacious  method  of  treatment  is  to  paint  each  wart  with  a 
solution  of  salicylic  acid  in  flexible  collodion  (Prescription  34). 

Presckiption  34. 
Metric.  Apothecary. 

Gramma. 

R   Acidi  salicylici 3175         R   Acidi  salicylici ^i ; 

Collodii 30|00  Collodii ^i. 

M.  M. 

This  is  applied  with  a  camel's-hair  brush  twice  a  day  for  three  days. 
Then  it  is  soaked  off  by  prolonged  bathing  in  warm  water,  with  the  addi- 
tion of  pumice  soap  if  there  is  no  inflammation.  This  will  usually  remove 
a  portion  of  the  wart,  and  the  process  should  be  repeated  as  long  as  any 
of  the  growth  is  left. 

The  treatment  with  salicylic  acid  is  not  always  successful,  and  recourse 
may  then  be  had  to  glacial  acetic  acid,  or  to  some  other  caustic,  carefully 
applied  ;  or  the  growth  may  be  excised. 


372  PEDIATRICS. 

LENTIGO. 

Lentigo  (freckles)  is  a  small  aggregation  of  pigment  deposited  in  the 
skin,  and  is  commonly  seen  in  children  of  ten  years  and  upward,  espe- 
cially in  those  of  light  complexion.  They  are  usually  situated  on  the  face 
and  hands,  but  may  occur  on  the  covered  portions  of  the  body,  a  fact  that 
led  Hebra  to  regard  them  as  not  due  to  the  action  of  the  sun.  There  can 
be  no  doubt,  however,  that  the  sun  is  the  chief  agent  in  their  production. 
Their  removal  is  often  difficult  and  requires  the  use  of  strong  irritants, 
such  as  corrosive  sublimate.  It  is  rarely  advisable  to  attempt  their  re- 
moval in  young  children. 

MELANODERMA  LENnOULAEIS  PROGRESSIVA. 

Melanoderma  lenticularis  progressiva  (Kaposi's  disease)  is  a  very  rare 
disorder,  and  is  seldom  met  with  in  this  country.  In  this  affection  spots 
of  pigment  like  freckles  appear  first  on  the  uncovered  parts  of  the  body, 
finally  extending  more  or  less  over  the  whole  cutaneous  surface.  The 
pigment-spots  are  the  first  lesions  seen,  but  later  an  atrophy  of  the  skin 
and  the  formation  of  small  angiomata  dotted  over  the  surface  take  place, 
giving  the  child  an  extraordinary  appearance.  The  disease  is  usually 
found  in  more  than  one  child  in  the  same  family,  and  its  etiology  is  very 
obscure.  Malignant  tumors  with  a  fatal  ending  often  result  from  this 
affection.  We  have  had  two  cases  under  our  observation  for  four  or  five 
years.  One  has  lately  died,  and  the  autopsy  showed  no  metastases  in 
the  internal  organs,  the  disease  proving  purely  a  local  affection  of  the  skin  : 
the  other  has  returned  to  the  hospital  in  a  worse  condition  than  ever 
before.  No  treatment  of  any  kind,  medical  or  surgical,  has  had  any  effect 
on  this  case. 

LICHEN. 

Many  of  the  aftections  that  were  formerly  included  under  the  head  of 
lichen  are  now  considered  by  most  authorities  to  belong  in  other  groups, 
/^~iiotably  in  that  of  eczema.  A  diagnosis  of  lichen  is  never  made  by 
American  dermatologists,  but  lichen  jjlanus  is  a  well-marked  skin  disorder 
which  retains  a  place  of  its  own.  It  rarely  occurs  in  children,  but  when 
present  it  follows  about  the  same  course  as  in  adults.  It  is  characterized 
by  firm  papules  of  an  irregular  shape  and  glistening  appearance,  of  a 
peculiar  reddish-blue  or  violet  color,  with  usually  a  slight  depression  in 
the  centre.  The  individual  papules  may  coalesce,  so  as  to  form  patches 
of  greater  or  less  extent,  covered  with  fine  scales.  It  is  often  accompanied 
by  great  itching  and  discomfort.  It  attacks  all  parts  of  the  body,  showing- 
a  predilection,  however,  for  the  flexor  surfaces  of  the  arms  and  legs.  It 
may  last  for  many  months,  and  in  the  most  favorable  cases  does  not  dis- 
appear for  several  weeks.  The  general  health  is  not  usually  affected,  ex- 
cept by  the  exhaustion  that  may  be  caused  by  intense  itching.  It  may 
be  confounded  Avith  a  papular  syphilide,  which  it  often  closely  simulates. 


DISEASES    OF    THE    SKLV.  373 

and  sometimes  it  may  be  mistaken  for  an  eczema.  Arsenic  is  of  value  in 
chronic  cases,  and  anti-parasitic  lotions  and  ointments,  especially  those 
containing  tar  in  some  form,  give  relief  as  external  applications. 

ICHTHYOSIS. 

The  disease  ichthyosis  as  it  occurs  in  infants  and  young  children  does 
not  differ  in  its  general  pathology  from  that  which  is  seen  in  adults.  It 
may  occur  in  intra-uterine  life,  and  is  then  designated  ftefol  ichthyosis. 

The  most  thorough  work  which  has  been  done  on  the  ichthyosis  of 
infancy  and  childhood  is  that  of  Ballantyne  of  Edinburgh,  who  designates 
that  form  which  has  occurred  in  utero  and  is  fully  developed  at  birth  as 
(1)  fcetal  ichthyosis,  while  the  form  which  begins  in  the  early  weeks  of 
infancy  he  speaks  of  as  (2)  ichthyosis  neonatorum. 

(1)  Foetal  Ichthyosis. — The  severity  of  foetal  ichthyosis  varies 
greatly. 

(a)  Severe  Form. — The  grave  form,  according  to  Ballantyne,  is  devel- 
oped probably  about  the  fourth  month  of  intra-uterine  life,  and  is  charac- 
terized at  the  time  of  birth  by  the  existence  all  over  the  body  of  horny  epi- 
dermic plates  separated  from  one  another  by  fissures  and  furrows,  associated 
with  deformities  of  the  mouth,  nose,  eyes,  lips,  and  limbs,  and  leading 
within  a  few  days  or  even  hours  to  the  death  of  the  infant.  As  in  most 
cases  infants  with  this  disease  are  born  alive,  foetal  ichthyosis  cannot  be 
considered  to  be  a  cause  of  intra-uterine  death.  The  disease  does  not 
seem  to  affect  especially  the  size  and  weight  of  the  infant.  As  a  rule,  the 
viscera  at  the  post-mortem  show  nothing  abnormal  except  an  unusual  de- 
gree of  congestion.  The  microscopic  examination  shows  no  extension  of 
the  keratinizing  process  on  any  of  the  mucous  membranes,  and  the  dis- 
ease is  an  abnormality  in  the  development  of  the  skin,  there  being  an 
excessive  proliferation  of  the  layers  of  the  epidermis. 

Symptoms. — In  the  early  hours  of  life  infants  with  fhis  disease  usually 
cry  loudly  and  continuously,  but  sometimes  the  cry  is  feeble  and  often 
very  peculiar.  The  respiration  is  usually  impeded  by  the  blocking  of  the 
nostrils  with  epidermal  masses.  Suction  is  rendered  difficult  or  altogether 
impossible  by  the  presence  of  ichthyotic  plates  around  the  mouth.  They, 
are,  however,  usually  able  to  swallow  readily.  As  a  rule,  nothing  abnor- 
mal is  found  in-  connection  with  the  urine  or  the  fasces.  Insomnia  is  a 
marked  symptom. 

These  infants  have  a  very  repulsive  appearance,  and  there  is  a  cadav- 
eric odor  arising  from  the  abnormal  condition  of  the  skin.  This  ichthy- 
otic condition  of  the  skin  is  usually  universal,  but  is  most  evident  upon 
the  face.  The  mouth  is  ordinarily  kept  open  by  the  contraction  of  the 
surrounding  parts,  and  from  its  angles  radiate  fissures  which  simulate  the 
rhagades  of  syphilis.  The  lips  are  thick  and  everted,  so  as  to  form  an 
irregular  entrance  to  the  gaping  buccal  cavity.  The  chin  is  receding. 
The  nose  can  scarcely  be  seen,  it  is  covered  so  thickly  with  the  epidermal 


374  PEDIATRICS. 

plates  around  the  nostrils.  There  is  usually  ectropion  of  both  eyelids, 
but  sometimes  only  of  the  upper  one,  the  orbits  seeming  to  be  occupied 
by  fleshy  tumors.  If,  however,  we  separate  the  swollen  eyelids,  the 
normal  eyeball  is  found  to  lie  beneath.  The  external  ear  seems  to  have 
disappeared  almost  entirely. 

In  contradistinction  to  the  opinion  formerly  held  that  foetal  ichthyosis 
was  a  general  seborrhcea,  it  is  now  generally  supposed  to  be  connected 
with  the  disease  as  it  occurs  in  the  adult. 

Prognosis. — The  prognosis  of  the  disease  is  almost  always  unfavor- 
able. 

Treatment. — The  treatment  should  be  active  and  directed  towards 
softening  the  epidermic  scales  by  means  of  warm  oil  inunctions. 

(6)  Mild  Form. — Besides  the  grave  form  of  foetal  ichthyosis,  there  is  a 
much  milder  form  of  the  disease.  It  develops  during  intra-uterine  life, 
and  shows  a  continuous  layer  of  a  substance  resembling  collodion  extend- 
ing over  the  whole  body  and  falling  off  in  small  flakes  resembling  pieces 
of  tissue-paper.  These  general  appearances  are  sometimes  accompanied 
by  ectropion  and  eclabium.  The  disease  is  not,  as  a  rule,  fatal,  and  often 
terminates  in  complete  or  partial  recovery.  There  have  not  been  any 
instances,  so  far  as  we  know,  of  an  infant  being  born  dead  with  this  form 
of  ichthyosis. 

Treatment. — The  treatment  of  this  second  form  should  be  by  con- 
tinual stimulation  of  the  child's  general  strength  and  by  great  care  of  the 
skin. 

(2)  Ichthyosis  Neonatorum. — Ichthyosis  in  the  new-born  infant,  in 
whom  at  birth  there  was  no  sign  of  the  disease,  may  occur.  It  presents 
the  same  appearances  as  the  milder  form  of  foetal  ichthyosis  and  the 
ichthyosis  of  the  older  child  and  the  adult. 

This  is  the  common  form  of  ichthyosis,  which  occurs  at  all  ages.  It 
begins  for  the  most  part  in  the  early  months  of  life,  is  essentially  chronic, 
and  is  very  intractable  to  treatment. 

Treatment. — It  should  be  treated  by  the  administration  of  a  warm 
bath  once  daily,  followed  by  an  inunction  with  glycerite  of  starch. 

SCLERODERMA. 
Scleroderma  is  a  disease  which  at  times  occurs  in  children  as  it  does 
in  adults.  It  consists  of  an  induration  of  the  skin  either  in  bands  or  in 
patches,  or  is  diffuse,  having  a  board-like  hardness,  so  that  the  skin  can- 
not be  raised  by  the  fingers  and  feels  as  though  it  were  tacked  down. 
Scleroderma  affects  the  motions  of  the  joints,  and  when  it  occurs  about 
the  chest  and  throat  may  interfere  with  respiration.  It  appears  to  be  a 
condensation  of  the  fibrous  layers  of  the  skin,  so  that  the  bundles  of 
connective-tissue  fibres  are  packed  closely  together  and  are  increased  in 
number.  It  is  chronic,  is  not  very  dangerous,  and  is  best  treated  by 
massage  and  lubricating  applications. 


DISEASES   OP   THE   SKIN.  375 

ACUTE  OIRCUMSCRIBED  OR  ANG-IO-NEUROTIO   CEDEMA. 

A  lesion  of  the  skin  which  has  been  termed  acute  circumscribed  oedema 
is  represented  by  the  sudden  appearance  of  circumscribed  swellings  of 
certain  parts  of  the  body,  varying  in  intensity  and  size  in  different  locali- 
ties. It  is  closely  allied  to  urticaria,  and  was  formerly  described  under 
the  name  oi  giant  urticaria.  We  do  not  know  much  about  either  its  cause 
or  its  pathology.  We  have  sometimes  met  with  it  in  children  in  whom  it 
was  evidently  of  reflex  origin,  depending,  probably,  upon  irritation  in 
various  parts  of  the  body,  such  as  the  mouth,  the  genitals,  and  the  gastro- 
enteric tract,  sometimes,  probably,  of  toxic  origin. 

It  is  not  dangerous,  may  occur  at  any  age,  and  its  treatment  is  simply 
symptomatic. 

The  following  cases  illustrate  the  disease  : 

A  little  boy,  two  and  one-half  years  old,  had  had  diarrhoea  during  the  summer, 
and  had  been  left  in  rather  a  weak,  debilitated  condition.  He  had  for  some  weeks 
been  pale,  fretful,  and  constipated.  His  appetite  had  been  capricious,  and  he  had  not 
cared  to  take  any  food  but  milk.  When  he  was  nineteen  months  old  an  egg  had  been 
given  to  him,  which  he  vomited,  and  later  a  slight  swelling  of  both  eyes  had  occurred, 
lasting  for  a  day  or  two. 

When  we  saw  the  child  the  history  that  was  given  was  that  in  the  morning  he 
had  eaten  an  egg.  Soon  after  he  became  rather  dull  and  cross,  but  did  not  vomrt. 
A  slight  swelling  of  both  eyes  was  then  noticed,  and  later,  when  I  saw  him,  the  right 
eye  was  very  much  swollen,  so  that  the  conjunctiva  was  corrugated,  and  the  tissues 
of  the  eyelids  and  of  the  cheek  under  the  eye  were  so  swollen  that  the  eye  itself  could 
be  examined  only  with  the  greatest  difficulty.  Each  time  that  the  child  had  eaten  an 
es,^  this  swelling  occurred  in  about  fifteen  minutes.  In  the  course  of  a  few  hours  the 
swelling  passed  off,  and  did  not  return.  An  examination  of  the  urine  showed  nothing 
abnormal. 

Another  instance  of  this  kind  occurred  in  a  boy  of  three  years,  in  whom  the 
peripheral  irritation  was  evidently  dependent  upon  a  tight  and  irritating  prepuce.  In 
this  case  sudden  oedematous  swellings  of  the  fingers  and  backs  of  the  hands  would 
occur  at  irregular  intervals,  lasting  for  a  few  hours,  and  would  then  entirely  disappear. 
These  manifestations  continued  until  the  child  was  circumcised,  since  which  time 
tne  symptoms  have  not  returned.  In  this  case,  also,  the  urine  was  found  to  be 
normal. 


DIVISION    VIII. 

SPECIFIC     INFECTIOUS      DISEASES. 


The  number  of  infectious  diseases  which  are  supposed  to  be  caused 
by  some  specific  infection  is  so  rapidly  increasing  tliat  at  present  no  defi- 
nite classification  of  them  can  be  made.  In  like  manner  our  knowledge 
of  the  specific  organism  which  in  an  individual  case  produces  the  disease 
is  so  continually  advancing  that  we  can  only  make  a  provisional  division 
into  somewhat  arbitrary  groups  of  the  diseases  which  we  speak  of  as 
infectious.  Tlius,  in  certain  diseases,  tuberculosis,  cerebro-spinal  menin- 
gitis, typhoid  fever,  diphtheria,  epidemic  influenza,  malaria,  tetanus  neo- 
natorum, erysipelas,  certain  forms  of  infectious  diarrhcEa,  and  cholera 
asiatica,  the  micro-organism  is  known  ;  while  in  others,  such  as  epidemic 
parotitis,  pertussis,  sj^philis,  and  rheumatic  fever,  which  are  evidently  just 
as  infectious,  the  specific  micro-organisms  have  not  been  demonstrated 
beyond  all  question  of  doubt.  Again,  there  are  certain  infectious  diseases 
which  have  usually  been  classed  in  a  group  by  themselves  on  account  of 
the  marked  similarity  which  they  present  in  their  general  characteristics. 
This  group,  as  a  whole,  has  been  designated  as  the  exanthemata,  and 
comprises  scarlet  fever,  measles,  rubella,  variola,  and  varicella. 

TUBERCULOSIS. 

Tuberculosis  is  an  infectious  disease  due  to  the  invasion  of  the  tissues 
by  the  tubercle  bacillus. 

General  Etiology. — Intra-uterine  infection  of  the  foetus  by  a  tu- 
berculous mother  from  direct  infection  may  occur.  Infection  by  the 
father  from  the  mother,  or  from  the  ovum  of  the  mother  has  not  been 
proved.  In  the  great  majority  of  cases  the  child  is  infected  after  birth. 
This  infection  may  be  by  direct  inoculation  from  the  mouth,  as  in  the 
Jewish  rite  of  circumcision,  or,  as  is  the  most  common  means  of  trans- 
mission, from  the  inhalation  of  the  bacilH  contained  in  dry  sputum.  A 
less  common  mode  of  invasion  is  that  from  uncooked  food.  The  bacillus 
tuberculosis  may  be  present  in  cow's  milk,  and  very  exceptionally  in  the 
milk  of  human  beings. 

The  question  of  the  relation  of  bovine  tuberculosis  to  human  tuber- 
culosis and  the  danger  of  infecting  man  from  the  milk  of  tuberculous  cows 
376 


SPECIFIC    LXFECTIULS    DISEASES.  377 

have  received  renev^'ed  attention  of  late.  The  researches  of  several  in- 
vestigators, particularly  those  of  Smith,  seem  to  show  that  the  bovine 
tubercle  bacillus  is  more  virulent  for  certain  species  of  animals  than  the 
human  tubercle  bacillus.  Whether  the  two  organisms  are  distinct  or 
whether  the  differences  which  have  been  noticed  between  them  are  simply 
modifications  brought  about  by  the  adaptations  of  the  bovine  bacillus  to 
the  different  conditions  in  the  human  body  are  points  still  to  be  deter- 
mined. The  weight  of  evidence,  however,  in  regard  to  infection  from 
milk  is  c|uite  sufficient  to  justify  the  following  practical  conclusions  : 

(1)  That  tuberculosis  in  many  cases  may  be  transmitted  to  animals 
either  through  the  ingestion  or  inoculation  of  the  milk  of  cows  that  are 
tuberculous.  (2)  That  the  milk  of  such  cows  may  be  infectious  even 
when  there  is  no  tubercular  disease  of  the  udders.  (3)  That,  therefore, 
the  milk  of  certain  tuberculous  cows  contains  living,  virulent  tubercle 
bacilli.  (4)  That,  whereas,  from  the  nature  of  the  case,  it  is  impossible 
by  direct  experimentation  to  prove  that  the  milk  of  certain  tuberculous 
cows  is  pathogenic  for  man,  nevertheless  the  clmical  evidence  of  compe- 
tent observers,  strengthened  by  the  results  of  animal  experimentation, 
makes  it  practically  certain  that  tuberculosis  may  be  produced  in  man  by 
the  ingestion  of  the  milk  of  infected  cows.  (5)  That  it  is,  therefore,  of 
the  utmost  importance  that  the  milk  supply,  especially  that  which  is  used 
as  food  for  infants  and  young  children,  shall  be  from  an  absolutely  relia- 
ble source. 

The  infection  of  food  by  flies  carrjing  the  bacilli  from  one  point  to 
another  is  possible.  Direct  infection  may  also  take  place  by  the  skin,  and 
in  these  cases  it  produces  a  local  lesion.  The  bacilli  may  pass  through  a 
mucous  membrane  without  infecting  it,  and  may  be  taken  up  by  the 
lymphatics  and  carried  to  the  lymph-nodes  where  their  progress  is  ustially 
arrested  for  some  time. 

Tuberculosis  is  a  very  prevalent  affection  in  early  life.  It  is  very  rare 
in  the  new-born  and  infrec{uent  in  the  first  three  months  of  life.  After 
this  age  the  number  of  eases  increases  rapidly,  and  the  disease  is  very 
common  in  the  latter  part  of  the  first  year  and  in  the  second  year,  grad- 
ually growing  less  common  as  puberty  is  approached.  The  presence  of 
tuberculosis  in  children  is  very  much  underestimated.  In  two  hundred 
and  twenty  autopsies  of  diphtheria,  tubercular  lesions  were  found  usually 
in  the  lungs,  and  sometimes  in  the  lymph-nodes  of  the  mesentery,  in  six- 
teen cases.  The  disease  is  very  much  more  common  in  young  children 
than  has  been  supposed,  and  it  may  exist  before  there  are  any  symptoms 
at  ail. 

The  bacilli  find  entrance  into  the  body  in  various  ways.  The  chief 
mode  of  entrance  is  probably  through  the  respiratory  tract.  The  organ- 
isms may  also  enter  through  the  alimentary  canal  or  by  means  of  the 
skin.  As  a  rule,  where  the  bacillus  finds  an  entrance  into  the  tissue  it 
produces  at  that  point  the  characteristic  lesion  of  the  disease.     In  other 


378  PEDIATRICS. 

cases  close  examination  fails  to  reveal  any  lesions  at  the  point  of  entry, 
although  this  does  not  preclude  the  possibility  that  the  lesions  may  be 
present.  It  is  probable  that  the  bacilli  enter  into  the  circulation  in  small 
numbers,  and  are  conveyed  to  various  tissues  of  the  body,  as  the  bones  or 
joints,  and  the  disease  may  appear  as  a  primary  infection  in  organs  remote 
from  the  point  of  entrance.  Frequently  the  bacilli,  without  apparently 
producing  any  lesions  at  the  point  of  entry,  enter  into  the  lymphatics  and 
are  carried  to  the  lymphatic  glands  in  which  the  disease  first  appears. 
Having  gained  an  entry  into  the  tissue  the  disease  always  extends  by 
means  of  the  bacilli,  which  are  carried  from  place  to  place  through  the 
natural  canals  or  channels  of  the  lymphatics  which  are  in  proximity  to 
the  diseased  focus,  or  by  means  of  the  blood.  In  all  cases  of  tuberculosis 
it  is  probable  that  there  is  some  infection  of  the  blood.  A  few  bacilli 
find  their  way  into  the  blood,  and  are  deposited  by  it  in  those  organs  in 
which  the  circulation  is  most  favorable  for  their  arrest.  We  have  an  ex- 
ample of  this  in  the  almost  constant  miliary  tuberculosis  of  the  liver  when 
the  infection  is  elsewhere.  At  times  the  bacilli  find  their  way  mto  the 
blood  in  large  numbers.  This  general  infection  of  the  blood  is  due  either 
to  a  tuberculosis  of  the  blood-vessels  or  to  a  tuberculosis  of  the  thoracic 
duct.  The  bacilli,  entering  into  the  blood  in  large  numbers,  are  conveyed 
into  the  different  organs  of  the  body  and  give  rise  to  the  condition  known 
as  acute  miliary  tuberculosis. 

Predisposition. — The  predisposition  to  tuberculosis  may  be  hereditary 
or  acquired.  It  is  hereditary  in  the  sense  that  the  individual  inherits 
tissues  which  are  more  or  less  receptive  to,  and  which  provide  a  favorable 
material  for  the  development  of  the  tubercle  bacillus.  In  diseases  result- 
ing in  a  great  reduction  of  the  vitality,  and  in  certain  acute  infectious  dis- 
eases, such  as  measles,  pertussis,  and  epidemic  influenza,  a  tuberculous 
predisposition  seems  to  be  acquired.  Bad  food  and  poor  hygienic  surround- 
ings, especially  absence  of  sunlight  in  the  crowded  tenement  districts  of 
-large  cities,  render  the  tiss-ues  more  vulnerable  to  the  tubercle  bacillus. 
In  like  manner  any  debilitating  disease,  by  lowering  the  resistance  of  the 
tissues,  acts  as  a  predisposing  cause.  Repeated  attacks  of  catarrhal  in- 
flammation of  the  mucous  membrane  of  the  nose,  throat,  bronchi,  or 
intestinal  tract  render  these  parts  more  vulnerable.  Infectious  diseases, 
especially  those  in  which  the  respiratory  organs  are  afl'ected,  predispose 
to  tuberculosis.  In  these  cases  it  would  seem  that  the  bacilli  have  been 
latent  in  the  lymph-nodes  surrounding  the  bronchi  until,  under  the  irrita- 
tion of  the  new  disease,  they  become  active  again. 

General  Pathological  Anatomy. — Tuberculosis  is  characterized  by  the 
production  of  tissue  in  which  there  is  proliferation  and  an  inflammatory  ex- 
udation. The  proliferation  of  tissue  leads  to  the  formation  of  epitheUoid  and 
giant  cells.  The  inflammatory  exudation  may  be  serous,  fibrinous,  or  puru- 
lent. Usually  in  the  tubercular  lesions  there  is  both  the  tissue  proliferation 
and  the  inflammatory  exudation.    The  proliferation  of  tissue  occurs  in  the 


SPECIFIC   INFECTIOUS   DISEASES.  379 

form  of  small  nodules  which  are  called  miliary  tubercles.  The  tubercu- 
lous tissue  is  further  characterized  by  a  form  of  necrosis,  and  the  necrotic 
tissue  has  a  tendency  to  soften  and  break  down.  These  miliary  tubercles 
often  coalesce  so  as  to  form  what  is  known  as  conglomerate  tubercles.,  in 
which  the  process  of  necrosis  is  especially  marked,  giving  rise  to  the 
"cheesy"  nodules  so  characteristic  of  the  disease.  Certain  degenerative 
changes  are  common  in  tuberculosis.  Thus  fatty  degeneration  frequently 
occurs  from  the  diminished  oxygenation  due  to  the  destruction  of  lung 
tissue.  Again,  amyloid  degeneration  is  common  in  those  forms  of  tuber- 
culosis which  run  a  chronic  course,  and  in  whicli  there  is  marked  de- 
struction and  suppuration  of  tissue.  The  lesions  of  tuberculosis  are  very 
numerous,  and  in  the  child  do  not  differ  materially  from  those  which  are 
found  in  the  adult.  The  ordinary  chronic  tubercular  lesions  met  with  in 
the  adult  are  seldom  seen  in  children. 

The  younger  the  child  the  more  likely  is  tuberculosis  to  be  chiefly 
located  in  the  lung.  As  the  child  grows  older  the  meninges  are  commonly 
affected,  and  later  the  peritoneum,  intestines,  and  joints.  During  the  first 
two  years  of  life  the  lesions  of  meningeal  tuberculosis  are  rare  in  com- 
parison with  the  period  beginning  with  the  third  year,  and  the  pulmonary 
lesions  usually  result  fatally  before  there  has  been  extensive  invasion  of 
the  intestines  and  joints.  As  the  child  passes  into  its  third  year  the 
marked  pulmonary  lesions  lessen  in  frequency  and  the  meningeal  forms 
become  more  common.  Later  the  joints  become  a  prominent  nidus  for 
meningeal  infection,  and  in  older  children  the  peritoneum,  intestines,  and 
mesenteric  lymph-nodes  show,  more  commonly,  marked  lesions.  At  all 
ages,  however,  there  are  usually  found  pulmonary  lesions  more  or  less 
marked  whenever  infection  has  taken  place  with  the  tubercle  bacillus. 

Prophylaxis. — In  considering  the  question  of  prophylaxis  in  tubercu- 
losis, special  attention  should  be  paid  to  what  has  already  been  said  of  the 
modes  of  invasion  and  of  predisposition.  In  all  cases  in  which  there  is 
a  family  history  of  tuberculosis  the  child  should,  if  possible,  be  surrounded 
with  unusual  precautions ;  a  change  from  a  severe  to  a  mild  climate, 
especial  care  of  even  mild  catarrhal  affections  of  the  mucous  membranes, 
much  fresh  air,  but  dry,  warm,  fresh  air,  protection  from  inhalation  of  dust, 
rooms  with  a  sunny  exposure,  and  freedom  from  living  in  the  house  with 
a  tuberculous  individual,  are  precautions  especially  to  be  observed.  Ex- 
posure to  the  diseases  which  have  been  mentioned  as  most  likely  to  be 
followed  by  tuberculosis  should  be  carefully  avoided.  Tuberculous  nurses 
should  never  be  allowed  to  take  care  of  children,  tuberculous  individuals 
should  not  be  allowed  to  kiss  children,  and  the  sputum  from  a  tuberculous 
individual  should  be  destroyed  at  once  before  it  has  become  dried.  A 
tuberculous  mother  or  wet-nurse  should  not  be  allowed  to  nurse  an  infant. 
The  animals  which  provide  milk  should,  at  stated  intervals,  be  carefully 
tested  with  tuberculin,  and  when  the  source  of  the  milk  is  not  known  or 
doubtful,  the  milk  should  be  heated  to  68.3°  C.  (155°  F.)  for  half  an  hour. 


380  PEDIATRICS. 

The  following  case,  seen  in  consultation  with  Dr.  W.  L.  Richardson 
and  Dr.  H.  P.  Jacques,  illustrates  the  importance  of  prophylaxis : 

A  boy,  five  years  old,  died  of  tubercular  meningitis.  The  autopsy  showed  exten- 
sive tubercular  lesions  of  the  meninges  with  enlarged  bronchial  lymph-glands  and 
cheesy  nodules  at  the  apices  of  both  lungs.  The  child  up  to  the  time  of  the  attack 
had  always  been  perfectly  well.  There  was  no  history  of  tuberculosis  in  the  family. 
There  were  several  other  children,  none  of  whom  had  ever  shown  any  symptoms  con- 
nected with  tuberculosis.  This  boy,  at  the  age  of  fourteen  months,  was  placed  in  the 
charge  of  a  nurse,  who  remained  with  him  until  he  was  four  and  a  half  years  old. 
Just  before  leaving  the  child,  she  was  brought  into  especially  close  connection  with 
him  while  his  parents  were  away  for  some  weeks.  The  child  was  very  fond  of  her, 
insisted  on  being  in  her  lap  a  great  deal,  kissed  her  on  the  mouth,  slept  in  her  bed, 
and  kept  her  in  the  nursery  with  him  continuously.  The  nurse,  while  taking  care  of 
the  child,  developed  tuberculosis  of  the  lungs  and  subsequently  died  of  this  disease. 
Other  cases  of  this  kind  have  been  known  to  occur. 

General  Symptomatology. — After  a  variable  period  of  loss  of  weight 
and  general  health,  wdiich  especially  occurs  in  cases  in  which  acute  mili- 
arj  tuberculosis  is  secondary  to  measles  or  to  pertussis,  the  infant 
begins  to  have  an  irregular  type  of  fever,  cough,  and  general  symptoms, 
such  as  diarrhoea,  capricious  appetite,  anaemia,  and  change  of  tempera- 
ment. In  some  cases  the  disease  appears  with  a  sudden  rise  of  tempera- 
ture and  advances  very  rapidly,  but  it  is  often  of  a  subacute  type,  and 
frequently,  unless  the  tuberculosis  markedly  affects  some  organ,  such  as 
the  lung,  the  symptoms  are  very  obscure,  death  finally  taking  place  from 
exhaustion  or  from  tlie  development  of  some  localized  condition,  such 
as  tubercular  meningitis  or  some  acute  pulmonary  complication,  bronclio- 
pneumonia  being  especially  common. 

General  Diagnosis. — From  what  has  been  said  concerning  the  symp- 
toms of  tuberculosis,  it  is  evident  that  when  no  localized  tubercular 
lesions  are  found,  the  diagnosis,  excepting  by  supposition,  is  not  pos- 
sible. It  is  probable,  however,  that  w^hen  more  is  known  regarding 
the  use  of  tuberculin  in  infants  and  in  young  children,  this  method  of 
diagnosis  will  be  more  frequently  used,  and  will  prove  of  value  by  pro- 
viding us  Avith  a  safe  method  for  detecting  an  incipient  tuberculosis, 
and  thus  aid  us  in  preventing  the  development  of  later  and  more  serious 
lesions. 

Tuberculin  Test. — The  technique  of  the  tuberculin  test  as  described 
by  Koch  i?  as  follows :  One  c.c.  of  tuberculin  added  to  999  c.c.  of 
distilled  water  equals  titV-oi  ^^'^^  1  c.c.  of  this  solution  equals  1  milli- 
gramme. The  dose  of  this  solution  for  an  infant  or  young  child  is  from 
2  to  5  c.c.  In  using  this  test  a  record  of  the  child's  temperature  must 
first  be  kept  every  two  hours  for  twenty-four  hours.  If  it  is  then  found 
that  the  temperature  is  irregular  or  high  the  test  is  not  of  much  value. 
If,  however,  the  temperature  is  regular  and  not  over  38.3°  C.  (101°  F.), 
the  test  can  be  used,  and  has   been   found  in  our   experience   at   the 


SPECIFIC    INFECTIOUS    DISEASES.  381 

Infants'  Hospital  to  be  of  considerable  value.  After  the  part  of  the  skin  to 
be  injected  has  been  thoroughly  washed  first  with  soap  and  water,  and 
then  with  alcohol,  and  the  hands  of  the  operator  and  the  syringe  disin- 
fected, from  2  to  5  c.c.  of  the  solution  are  injected  into  the  arm  or  leg.  If 
the  child  is  not  tubercular  no  symptoms  will  be  noticed.  If  it  is  tubercular 
the  temperature  will  rise  in  from  eight  to  twenty-four  hours  after  the 
injection,  and  will  fall  again  within  about  twenty-four  honrs.  During  the 
period  of  reaction  there  may  be  a  certain  amount  of  malaise,  but  in  our 
experience  there  is  little  or  no  danger  of  serious  results.  A  positive 
reaction  will  be  obtained  in  about  95  per  cent,  of  cases  of  tuberculosis.  A 
negative  reaction  does  not  positively  exclude  tuberculosis,  although  it  is 
very  strong  evidence  against  it. 

General  Prognosis. — The  prognosis  of  tuberculosis  in  early  life  is 
almost  invariably  bad.  Even  when  the  bacilli  have  been  encapsulated 
they  are  liable  at  any  time  to  become  active. 

General  Treatment. — Of  especial  importance  in  the  treatment  of 
children  with  tuberculosis  in  any  form  is  the  general  hygiene,  fresh,  dry 
air,  a  warm,  dry  climate,  and  plenty  of  sunshine.  The  treatment  by 
drugs  is  ven^  unsatisfactory  and  usually  without  good  results.  In  some 
cases  cod-liver  oil  seems  to  be  of  temporary  benefit.  Cream  is  useful 
and  should  be  given  when  cod-liver  oil  is  not  well  borne  or  is  especially 
distasteful.  A  general  diet  adapted  to  the  age  and  condition  of  the 
especial  child,  and  the  treatment  of  symptoms  which  arise  when  special 
organs  are  involved,  are  the  only  rational  procedures.  Tuberculin  has 
not  as  yet  been  proved  to  be  sufficiently  valuable  as  a  therapeutic  agent 
to  be  accepted  by  the  medical  profession  in  general. 

The  following  case  illustrates  how  extremely  latent  and  masked  may 
be  the  symptoms  of  tuberculosis  : 

An  infant,  seven  months  old,  was  in  the  Infants'  Hospital  from  October  until 
December.  During  this  time  it  became  extremely  emaciated,  diarrhoea  occurred  from 
time  to  time,  and  there  was  an  irregular  and  varying  temperature,  never  especially  high. 
It  had  a  purulent  discharge  from  the  right  ear,  and  a  serous  discharge  from  the  left  ear. 
There  were  no  other  symptoms  and  no  abnormal  physical  signs.  It  failed  rapidly  and 
died.  The  autopsy  showed  miliary  tuberculosis  of  the  pleura,  spleen,  kidney,  and 
liver,  chronic  tuberculosis  of  the  bronchial  lymph-glands  and  of  the  lung,  and  broncho- 
pneumonia. 

GENERAL  TUBERCULOSIS.— General  tuberculosis  in  early  life 
may  be  acute  or  chronic.  It  is  now  believed  that  in  every  case  there  is  a 
tubercular  focus,  usually  in  a  gland  or  in  the  lung,  from  which  the  general 
infection  has  emanated.  The  early  symptoms  of  a  general  tubercular  in- 
vasion vary  much  and  are  often  obscure.  As  a  rule,  they  appear  before 
the  symptoms  of  local  tuberculosis  of  an  especial  organ,  and  are  repre- 
sented by  irregular  temperature,  anaemia,  and  a  general  lowering  of  the 
nutrition  and  vitality. 


382  PEDIATRICS. 

ACUTE  MILIARY  TUBEROULOSIS. 

The  term  acute  is  somcAvhat  misleading  iii  speaking  of  miliary  tuber- 
culosis, since  this  form  of  general  tuberculosis  varies  greatly  in  the  rapidity 
of  its  invasion  and  in  the  intensity  of  its  symptoms,  according  to  the 
rapidity  mtli  which  the  bacilli  gain  an  entrance  to  the  circulation,  and  in 
proportion  to  tlie  susceptibility  of  the  individual  to  their  virulence.  Some 
of  these  cases  are  extremely  acute,  while  others  are  markedly  chronic. 
There  are  certain  organs  of  the  body  which  are  rarely  affected.  This 
must  be  attributed  to  the  fact  that  the  organs  in  question  do  not  offer 
favorable  conditions  for  the  development  of  the  bacillus.  Thus,  it  is  ex- 
tremely common  for  the  bronchial  lymph-nodes  and  the  lungs  to  be 
affected,  while  it  is  rare  for  the  stomach  or  the  genito-urinary  org-ans  to 
be  markedly  involved.  Especially  noticeable  in  comparison  with  those 
acute  cases  which  occur  usually  in  somewhat  older  children  with  pro- 
nounced symptoms,  and  representing  the  form  which  is  called  the 
typhoidal  type  of  the  disease,  is  the  clinical  picture  represented  by  those 
cases  which  occur  in  early  infancy,  and  wiiich  are  markedly  subacute 
rather  than  acute,  simulating  closely  infantile  atrophy. 

Pathological  Axatomy. — The  disease  is  characterized  by  the  formation 
of  nodules,  varying  in  size  and  character,  in  the  different  organs  and  tissues 
of  the  body.  As  a  rule,  the  nodules  (miliary  tubercles)  are  larger  and  not 
so  characteristic  as  in  the  adult.  x\s  compared  with  the  adult,  they  vary 
somewhat  m  their  distiilDution.  They  are  much  more  numerous  and 
larger  m  the  liver  in  the  case  of  the  child  than  they  are  in  the  adult. 
The  condition  is  produced  by  the  entry  of  the  tubercle  bacillus  in  large 
numbers  into  the  blood.  They  may  enter  the  blood  through  a  blood- 
vessel, or  by  means  of  infection  of  the  thoracic  duct  following  infection  by 
the  lymph-nodes.  It  is  not  probable  that  they  multiply  directly  in  the 
circulating  blood,  but  they  may  multiply  in  the  blood-vessels  of  organs  in 
which  the  blood-stream  is  comparatively  inactive,  as  in  the  liver. 

(1)  Acute  Miliary  Tuberculosis  Simulating-  Typhoid  Fever. — Symp- 
toms.— The  symptoms  of  this  type  of  the  disease  are  very  indefinite.  There 
is  rapidly  progressive  emaciation.  The  temperature  is  irregular,  and  fluctu- 
ates fi'om  37.2°  or  37.7°  C.  to  40°  or  40.5°  C.  (99°  or  100°  F.  to  104° 
or  105°  F.),  or  even  higher.  The  respirations  are  often  accelerated  beyond 
what  can  be  explained  by  the  fever,  and  physical  signs  are  markedly  alDsent 
in  the  lungs.  The  pulse  is  rapid.  Certain  cases  of  this  class  simulate  typhoid 
fever  by  presenting  symptoms  of  apathy,  headache,  slightly  enlarged  spleen, 
and  tympanites.  In  making  the  differential  diagnosis  from  typhoid  fever  it 
is  well  to  take  into  consideration  the  family  history  in  regard  to  tubercu- 
losis, and  also  whether  the  child  has  been  living  where  typhoid  was  preva- 
lent. Although  no  leucocytosis  is  present  m  either  disease,  yet  it  has  been 
held  that  while  in  typhoid  there  is  a  relative  increase  in  the  small  mononu- 
clear cells,  there  is  in  tuberculosis  a  relative  decrease.     In  other  respects 


SPECIFIC    INFECTIOUS    DISEASES.  383 

the  blood  simply  shows  the  characteristics  of  a  secondary  ansemia.  The 
Widal  reaction  is  absent  in  tuberculosis.  The  tubercle  bacillus  may  or 
may  not  be  present  in  the  sputum.  In  some  cases  the  bacilli  of  typhoid 
and  tuberculosis  have  been  found  in  the  urine.  The  tuberculin  test  is 
seldom  of  value  in  these  cases,  as  the  fever  is  contmuous  and  usually 
sufficiently  high  to  prevent  the  characteristic  rise  of  temperature  from 
being  perceptible.  The  less  regular  temperature,  the  rapid  respirations, 
and  the  absence  of  rose  spots  are  significant  of  tuberculosis.  Finally, 
in  most  cases  the  tendency  of  typhoid  fever  is  gradually  to  recover,  while 
tuberculosis  shows  progressive  emaciation  and  the  development  of  new 
symptoms  according  as  other  organs  are  involved.  In  some  cases  malaria 
may  simulate  tuberculosis,  but  the  presence  of  the  Plasmodium  as  deter- 
mined by  a  blood  examination  and  the  response  to  the  treatment  with 
quinine  serve  to  separate  this  disease  from  tuberculosis. 

Prognosis. — The  course  of  this  type  of  the  disease  is  short  and  the 
result  invariably  fatal. 

(2)  Acute  Miliary  Tuberculosis  Simulating"  Infantile  Atrophy, — 
Symptoms. — We  have  frequently  had  patients  brought  into  the  Infants'  Hos- 
pital in  whom  it  was  impossilDle  to  differentiate  in  the  beginning,  and  per- 
haps for  weeks,  what  eventually  proved  to  be  miliary  tuberculosis.  The 
symptoms  in  these  cases  are  simply  progressive  emaciation,  with  occasion- 
ally a  temperature  moderately  raised,  but  in  no  way  differing  from  what  is 
frequently  found  in  the  atrophic  condition  in  which  a  slight  disturbance  of 
digestion  may  cause  a  similar  rise  in  temperature.  These  tubercular 
cases  simply  die  of  exhaustion,  with  no  physical  signs  developing  during 
life,  the  disease  being  completely  masked  and  only  recognized  at  the 
autopsy.  In  some  cases,  however,  after  a  variable  period,  physical  signs 
can  be  detected  in  the  lungs,  the  temperature  rises  more  and  more,  and 
there  may  be  cough  and  accelerated  respirations.  In  these  cases,  also, 
there  are  at  times  diarrhoea  and  general  gastro-enteric  disturbance,  but 
these  conditions  depend  entirely  on  the  reduced  condition  of  the  infant 
and  not  upon  tubercular  lesions  of  the  intestine.  The  temperature  in 
these  cases  varies  from  37.2°  to  38.8°  C.  (99°  to  102°  F.).  It  must  be 
remembered  that  infants  with  simple  infantile  atrophy  at  times  develop 
non-tubercular  broncho-pneumonia  and  die  of  it,  so  that  a  diagnosis 
made  by  finding  physical  signs  in  the  lungs  in  those  cases  which  simulate 
infantile  atrophy  is  not  conclusive,  as  the  signs  do  not  necessarily  prove 
that  tuberculosis  is  present.  On  the  other  hand,  acute  miliary  tubercu- 
losis of  the  lung  usually  presents  no  physical  signs  whatever,  so  that  the 
differential  diagnosis  between  many  cases  of  acute  miliarj^  tuberculosis 
and  infantile  atrophy  must  be  held  in  abeyance,  and,  unless  the  tuber- 
culin test  can  be  used,  cannot  be  made  except  at  the  autopsy. 

Prognosis. — The  prognosis  is  fatal. 

Treatment. — The  general  treatment  of  acute  miliary  tuberculosis  is 
essentially  symptomatic  and  by  the  use  of  stimulants.     When  the  disease 


384 


PEDIATRICS. 


simulates  typhoid  fever,  the  treatment  should  be  such  as  is  described  in 
that  disease,  on  the  supposition  that  it  may  turn  out  to  be  typhoid.  When 
it  simulates  infantile  atrophy,  however,  the  CHAET  5. 

treatment  should  be  the  same  as  in  that 
disease,  and  is  essentially  dietetic. 

The  following  case  was  one  of  acute 
miliary  tuberculosis : 

An  infant,  one  and  a  half  years  old,  was 
brought  to  the  Infants'  Hospital  to  be  treated  for 
an  attack  of  bronchitis.  On  entrance  it  was  much 
emaciated  and  failed  rapidly.  No  marked  signs 
beyond  a  subacute  bronchitis  were  found.  There 
was  at  times  a  slight  cough.  The  temperature  was 
moderately  raised  and  of  an  irregular  type.  The 
thorax  and  legs,  especially  the  buttocks,  showed 
numerous  subcutaneous  abscesses,  and  there  were 
also  a  few  on  the  head.  Five  days  before  the  in- 
fant died  the  temperature  rose  as  represented  on 
Chart  5.  The  post-mortem  examination  showed 
that  there  was  chronic  tuberculosis  of  the  bron- 
chial glands,  with  acute  miliary  tuberculosis  of  the 
pleura,  lungs,  spleen,  kidneys,  liver,  and  meninges.  Acute  miliary  tuberculosis. 


Days  of  Disease 

F. 

c. 

107 
106 
105 
104 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

44.6° 
41.1° 
40.5° 
40.0° 

3 

103 
102 

J 

Q 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 
35.5° 

V 

/ 

101 

100 

99 

\ 

Y 

y 

NORMAL 
TEMP.g 

98 
97 
96 

u 

— 



95" 

35.0° 

CHRONIC  GENERAL  TUBERCULOSIS. 

In  addition  to  the  lesions  which  characterize  acute  miliary  tuberculosis, 
a  chronic  general  form  of  tuberculosis  occurs  in  certain  cases.  The  symp- 
toms are  more  marked  than  in  the  acute  form,  and  usually  are  so  closely 
connected  with  the  bronchial  lymph-nodes  and  the  lungs  that  it  is  more 
easily  diagnosticated.  This  chronic  general  tuberculosis  is  one  of  the 
more  common  forms  of  tuberculosis  in  children. 

LOCALIZED  TUBERCULOSIS. — Although  tuberculosis  may  by  a 
general  infection  invade  all  the  tissues,  thus  constituting  the  general  tuber- 
culosis just  described,  it  is  apt  to  be  so  pronounced  in  certain  parts,  and 
so  much  more  common  in  some  than  in  others,  that  these  localized  forms 
can  best  be  described  separately.  An  instance  illustrating  this  is  given  in 
the  lymph-nodes  of  the  neck  in  children  where  the  node  is  very  com- 
monly found  to  be  tuberculous,  and  yet  in  many  cases  no  trace  of  a  gen- 
eral tuberculosis  can  be  found  elsewhere. 


TUBERCULOSIS    OF    THE    LYMPH-NODES. 

Tuberculosis  of  the  lymph-nodes  is  an  exceedingly  common  form  of 
tuberculosis  in  children.  In  all  forms  of  tuberculosis  the  lymph-nodes  are 
affected.  The  tubercle  bacilli  come  in  very  close  relation  with  the  lymph 
spaces  and  ducts  and  are  carried  by  them  into  the  lymph-nodes  belonging 
to  the  part.     There  are  also  cases  of  tuberculosis  of  the  lymph-nodes  in 


SPECIFIC    LXFECTIUUS    DISEASES.  335 

which  the  disease  appears  to  be  primary  in  these  parts.  Such  cases 
are  found  in  tlie  lymph-nodes  of  the  neclv,  of  the  axillae,  and  of  the 
mesentery. 

Tuberculosis  of  the  lymph-nodes  appears  in  two  forms  :  (1)  the  nodes 
are  enlarged  and  contain  the  tubercular  tissue  in  the  form  of  miliary 
tubercle,  which  by  their  increase  and  coalescence  can  form  large  caseous 
areas ;  (2)  the  nodes  are  also  enlarged  in  the  form  of  diffuse  tubercles, 
leading  to  the  caseation  of  large  areas,  in  fact,  the  entire  node  may  be 
converted  in  consequence  of  this  caseation  of  the  diffuse  tubercular  tis- 
sue into  a  large  caseous  mass.  The  caseous  tissue  of  the  nodes  may 
soften,  break  down,  and  even  suppurate,  leading  to  the  formation  of  tuber- 
cular abscesses.  The  bacilli  having  entered  at  some  point  can  be  carried 
from  the  point  of  entrance  by  the  lymph-streams  into  the  nearest  lymphat- 
ics and  lymph-nodes,  without  the  production  of  local  lesions.  In  gen- 
eral, the  lymph-nodes  play  an  important  part  by  preventing  the  tubercle 
bacilli  from  entering  into  the  blood,  and  the  disease  from  extending  fur- 
ther. It  is  very  interesting  to  note  that  the  lymph-nodes  can  soften  and 
break  down  in  this  way  and  be  discharged,  and  that  no  further  infection 
need  follow. 

Tuberculosis  of  the  Cervical  Lymph-Nodes  (Scrofula). — The  most 
important  of  the  lymph-nodes  affected  in  tuberculosis  are  the  lymph- 
nodes  of  the  neck.  Invasion  of  the  cervical  lymph-nodes  may  occur 
primarily  by  infection  from  the  throat.  When  this  invasion  occurs  in 
connection  with  tuberculosis  of  the  lungs  the  infection  of  the  cervical 
nodes  is  probably  primary  to  the  pulmonary  lesions.  The  cervical 
lymph-nodes  are  more  commonly  affected  by  the  tubercle  bacillus  in  the 
early  period  of  childhood-  than  in  infancy,  in  which  the  infection  of  the 
bronchial  nodes  are  so  frequently  met  with.  When  the  term  scrofula 
was  in  more  general  use,  tuberculosis  of  the  cervical  lymph-nodes  was 
considered  as  one  of  its  most  frequent  manifestations ;  now  the  term  can 
be  dropped  entirely. 

Symptoms  and  Diagnosis. — In  cases  in  which  the  cervical  lymph-nodes 
begin  to  enlarge  in  a  marked  tuberculosis,  as  of  the  lung,  the  symptoms 
are  those  of  a  slow  process  extending  over  months,  with  a  tendency  to 
suppuration. 

The  diagnosis  in  these  secondary  cases  is  made  by  eliminating  the 
causes  of  glandular  enlargement  which  could  produce  a  similar  hyper- 
plasia by  reflex  action,  or  which  could  be  produced  by  some  other  organ- 
ism. The  diagnosis,  however,  is  chiefly  made  by  the  tubercular  history 
o-f  the  case,  as  in  the  majority  of  cases  the  nodes  under  these  circum- 
stances are  tubercular. 

Primary  tuberculosis  of  the  cervical  lymph-nodes  is  to  be  distinguished 
from  other  forms  of  infection  by  its  slow  progress,  by  its  greater  tendency 
to  suppuration,  and  also  by  the  fact  that  the  suppuration  as  a  whole  takes 
place  later  than  the  simple  form.    The  enlarged  cervical  nodes  due  to  syphi- 

25 


386 


PEDIATIUCS. 


lis,  Hodgkin's  disease,  or  malignant  growths  should  bo  ditferentialed  from 
tuljerculosis  of  the  cervical  lymph-nodes,  as  described  in  these  diseases. 

Prognosis. — ^The  prognosis  of  tuberculosis  of  the  cervical  lymph-nodes 
is  good,  the  exception  being  for  the  child  to  develop  tubercular  disease 
elsewhere.  The  prognosis  when  the  tuberculosis  is  secondary  to  tuber- 
©ulosis  elsewhere  varies  according  to  the  tubercular  lesions  from  which  it 
originates. 

Treatment. — When  the  tubercular  disease  has  extended  to  other 
organs  there  is  seldom  much  benefit  to  be  derived  from  the  treatment  of 
these  nodes,  xllthough  it  is  conceded  that  general  tuberculosis  following 
tubercular   cervical  adenitis   is  exceedingly  rare,   yet   there   have   been 


Fig.    100. 


Chronic  pulmonary  tuberculosis,  with  involvement  of  the  cervical  Ij-mph-nodes. 


cases  reported  in  which  such  mfection  has  taken  place,  and  the  glands 
should  be  removed  unless  they  have  grown  smaller  iu  a  number  of 
months,  at  any  rate  if  they  show  signs  of  softening.  A  change  of  climate 
and  out-of-door  life  is  indicated,  and  if  the  child  has  a  tubercular  inheri- 
tance, especial  care  should  be  taken  to  keep  the  naso-pharynx  and  throat 
in  a  healthy  condition.  Adenoid  growths  and  enlarged  tonsils  should  be 
removed.  Any  lesion  of  the  face  and  head  which  may  cause  irritation 
should  be  treated,  as,  by  their  reflex  action,  they  may  cause  increased 
activity  of  the  tuJDercle  bacilli. 

Medicines,  except  for  special  conditions,  such  as  anaemia,  are  useless. 


SPECIFIC    LXFECTIUUS    DISEASES.  387 

External  applications  of  an  irritating  nature  are  contra-indicated.  Pre- 
venting the  liead  from  rolling  from  side  to  side,  and  thus  pressing  on  the 
inflamed  glands,  can  sometimes  be  accomplished  by  various  mechanical 
devices  in  the  shape  of  collars.  The  operative  treatment  includes  not 
only  the  removal  of  the  gland,  but  the  removal  of  it  at  such  a  time  that 
the  smallest  scar  will  be  left,  as  in  many  cases  following  a  suppuration  of 
these  glands  unsightly  scars  are  left  which  disfigure  the  child  for  life. 
These  cases  should,  therefore,  be  placed  in  the  hands  of  a  skilful  surgeon. 

Fig.  100  represents  a  child  with  tuberculosis  of  the  cervical  lymph- 
nodes  in  a  case  of  marked  chronic  tuberculosis  of  the  lungs. 

Tuberculosis  of  the  Bronchial  Lymph-Nodes. — Of  all  the  lymph- 
nodes  in  the  body,  the  bronchial  lymph-nodes  are  probably  the  most  fre- 
quently infected,  due  to  the  fact  that  the  primary  focus  of  infection  is  so 
commonly  found  in  the  lungs,  and,  as  the  lymph  flows  from  the  lung 
towards  the  nodes,  the  nodes  may  be  infected  in  this  way  by  the  lung. 
Thus,  the  bronchial  lymph-nodes  protect  the  body  fi'om  general  infection, 
but  do  not  protect  the  lungs,  and  such  tubercular  lymph-nodes  can  be- 
come, moreover,  a  starting-point  for  further  extension  of  the  disease  after 
the  primary  lesions  by  which  the  lymph-nodes  themselves  became  infected 
have  been  recovered  from. 

Tuberculosis  of  the  broncliial  lympli-nodes,  if  it  is  extensive,  may  in- 
volve the  pneumogastric  nerve.  The  nodes  may  possibly  suppurate  into 
a  bronchus,  and  the  infection  can  in  tliis  way  also  extend  into  the  lungs. 

Symptoms. — Various  symptoms  may  arise  from  the  breaking  down  and 
ulceration  of  the  bronchial  lymph-nodes,  or  by  their  pressure  they  may 
cause  irritation  of  the  neigliboring  parts.  Thus,  an  annoying  cough  ma\ 
be  produced  by  local  irritation.  Loeb  has  reported  cases  in  which  the 
previous  symptoms  had  been  only  cough,  and  in  which  an  attack  of  suffo- 
cation caused  death.  Adelbert  and  Vogel  have  reported  cases  in  which 
ulceration  originating  from  these  points  has  resulted  in  death.  The 
physical  signs  are  indefinite  and  unreliable,  and  we  must  depend  upon 
the  general  symptoms  of  spasmodic  cough  and  dyspnoea,  without  an  ade- 
quate explanation  of  these  symptoms  being  found  elsewhere. 

Tuberculosis  of  the  Mesenteric  Lymph-Nodes. — Tuberculosis  of 
the  mesenteric  lymph-nodes  may  be  seen  without  any  evidence  of  tiiber- 
culosis  elsewhere  in  the  body,  or  it  may  be  found  in  connection  Avith 
intestinal  tuberculosis.  In  all  cases  the  infection  is  by  means  of  the 
intestine,  although  there  may  be  no  lesions  at  the  point  of  invasion. 

When  the  nodes  can  be  reached  or  definitely  localized,  they  should 
be  removed,  even  if  laparotomy  has  to  be  performed :  for  there  is  always 
danger  not  only  of  their  breaking  down  and  becoming  a  source  of  general 
tubercular  infection,  but  also  a  peritonitis  may  arise  suddenly  at  any  time 
from  acute  inflammation  of  the  peritoneum  originating  from  a  disintegrated 
node  and  ending  fatally  in  perhaps  a  few  days.  A  case  of  this  kind  is 
described  on  page  843. 


388  PEDIATRICS. 

TUBERCULOSIS  OF  THE  LARYNX  AND  TRACHEA. 

Tuberculosis  of  the  larynx  and  trachea  is  very  rare  in  infants  and  rare 
in  young  children.  When  it  is  present  it  is  invariably  secondary  to  tuber- 
culosis of  the  lungs.  The  symptoms  are  the  same  as  those  of  non-tubercu- 
lar disease  of  these  organs,  and  the  diagnosis  can  only  be  made  definitely 
by  finding  the  tubercle  bacillus  in  the  sputum. 

Treatment. — The  treatment  does  not  differ  from  that  of  the  non- 
tubercular  cases. 

TUBERCULOSIS  OF  THE  LUNGS. — The  tubercle  bacillus  may 
be  brought  to  the  lungs  by  means  of  the  blood  or  by  the  respiratory 
passages,  the  latter,  according  to  Northrup,  being  the  most  frequent  in 
children,  the  bacillus  entering  with  the  inspired  air  and  lodging  in  the 
mucous  lining  of  the  bronchi  or  in  the  alveoli.  When  carried  by  the 
blood  they  are  generally  scattered  throughout  the  tissue  and  give  rise  to 
miliary  tubercles.  In  some  cases  the  infection  may  arise  from  the  throat 
with  or  without  the  production  of  a  local  lesion,  the  bacilli  being  carried 
through  the  lymph-nodes  into  the  blood  and  from  the  right  side  of  the 
heart  to  the  lung.  Rarely  a  very  few  bacilli  may  be  brought  to  the  lungs 
by  the  blood.  They  may  affect  only  a  certain  definite  portion  of  the 
lung  and  give  rise  to  lesions  which  are  scarcely  distinguishable  from  the 
lesions  produced  by  the  entry  of  the  bacilli  through  the  respiratory 
passages.  Tuberculosis  of  the  lungs  may  occur  in  three  forms  :  (1)  acute 
miliary  tuberculosis,  (2)  the  more  diffuse  tubercular  pneumonia,  and  (3) 
chronic  tuberculosis  of  the  lungs. 

Ordinarily  the  distinction  made  between  acute  miliary  tuberculosis 
and  tubercular  pneumonia  lies  in  the  preponderance  of  the  exudative 
lesions  in  the  latter.  In  the  lungs  of  children  there  is  a  much  greater 
tendency  to  exudation  than  in  adults,  and  even  in  acute  miliary  tubercu- 
losis the  essential  proliferative  changes  are,  as  a  rule,  accompanied  by 
exudation.  There  is  a  further  difference  between  children  and  adults  in 
/^That  the  chronic  forms  of  tuberculosis  which  are  accompanied  by  exces- 
sive destruction  of  tissue,  with  inflammation  leading  to  a  formation  of 
fibrous  tissue,  and  producing  the  condition  known  as  fibroiditis,  are  seen 
to  a  much  less  degree  in  children  than  in  adults. 

(1)    ACUTE  MILL^LRY   TUBERCULOSIS   OF   THE   LUNG. 

Acute  miliary  tuberculosis  of  the  lung  has  been  described  on  page 
382  as  a  part  of  acute  general  miliary  tuberculosis.  It  presents  no  other 
symptoms,  when  the  acute  process  is  limited  to  the  lung,  than  those  which 
have  been  already  mentioned  as  occurring  in  the  acute  general  miliary 
tuberculosis.  There  may,  however,  be  a  formation  of  miliary  tubercles 
in  the  lung  in  combination  with  other  forms  of  tuberculosis  of  this  organ, 
the  formation  of  tubercles  being  a  more  chronic  process  than  in  the'  acute 
disease. 


SPECIFIC    LXFECTIOUS    DISEASES.  339 

(2)     ACUTE  TUBERCULAR  BRONCHO-PNEUMONIA. 

Etiology. — Acute  tubercular  broncho-pneumonia  is  common  in  chil- 
dren from  the  sixth  montli  to  the  fifth  year,  a  large  proportion  of  the 
cases,  however,  occurring  after  the  second  year.  It  may  begin  in  the 
lungs,  or  may  be  secondary  to  any  other  of  the  lesions  of  general  tubercu- 
losis, or  it  may  follow  any  non-tubercular  lesion  of  the  lungs,  such  as 
bronchitis  or  broncho-pneumonia.  It  is  common  in  children  who  have 
been  debilitated  by  previous  illness,  and  occurs  especially  after  measles, 
pertussis,  scarlet  fever,  and  diphtheria,  being  most  frequent  in  the  first 
two.  It  may,  however,  develop  in  perfectly  healthy,  well-nourished  chil- 
dren, and,  as  Osier  has  expressed  it,  may  be  a  terminal  process  in  cases 
in  which  a  local  tubercular  disease  exists  in  other  parts,  such  as  the  skin, 
bones,  lymph-nodes,  or  the  uro-genital  tract. 

Pathological  Anatomy. — The  infection  extends  by  means  of  the  bron- 
chi, and  the  lesions  extend  through  the  bronchi  and  the  alveoli  into  the 
surrounding  tissue.  This  is  a  true  pneumonia.  There  is  an  exudation  into 
the  alveoli  of  the  lungs,  which  consists  chiefly  of  fibrin  and  leucocytes.  In 
addition  to  this,  there  are  numbers  of  large  cells,  which  probably  arise  from 
proliferation  of  the  epithelium  lining  the  alveoli.  Both  the  exudative  and 
the  proliferative  cells  undergo  caseation,  and  the  tubercular  pneumonia 
may  occur  in  the  form  of  discreet  nodules  similar  to  ordinary  forms  of 
broncho-pneumonia,  or  in  the  form  of  larger  areas,  which  may  arise  either 
by  confluence  of  the  smaller  foci  or  by  the  simultaneous  affection  of  a 
large  area  of  the  tissue. 

As  in  the  other  forms  of  broncho-pneumonia,  the  initial  lesion  is  a 
bronchitis  and  peri-bronchitis,  the  distinguishing  tubercular  features  being 
caseation  and  necrosis  of  the  consolidation  with  the  presence  of  the 
tubercle  bacilli.  The  accompanying  phenomena  of  atelectasis  and  emphy- 
sema occur  as  they  do  in  non-tubercular  broncho-pneumonia.  In  some 
cases  the  non-tubercular  broncho-pneumonia  precedes  the  tubercular  dis- 
ease, this  occurring  particularly  after  measles,  scarlet  fever,  diphtheria, 
and  pertussis.  When  the  tubercular  broncho-pneumonia  follows  the  non- 
tubercular  form,  in  addition  to  the  lesions  of  the  latter  disease,  there  are 
found  true  tubercular  processes,  such  as  peri-bronchial  nodules,  tubercular 
infiltration,  and  caseous  areas. 

It  is  rare  for  the  tubercular  process  in  children  to  begin  at  the  apices 
of  the  lungs  and  gradually  extend  downward,  as  is  common  in  adults. 
When  this  occurs  it  is  usually  in  the  later  years  of  childhood,  when  the 
conditions  are  beginning  to  approximate  those  of  later  life. 

Tubercular  broncho-pneumonia  may  be  acute  or  chronic,  but  it  is 
rarely  very  chronic.  It  may  occur  in  Yerj  small  foci  apparently  following 
the  bronchi,  or  it  may  invade  a  much  larger  area  and  even  an  entire  lobe 
of  the  lung. 

Symptoms. — The   symptoms  of  acute   tubercular  broncho-pneumonia 


390  PEDIATRICS. 

are  very  similar  to  those  of  iion-tiiberciilar  broncho-pneumonia.  Ac- 
cording to  Osier,  in  most  cases  the  onset  of  the  disease  simulates  that  of 
the  ordinary  non-tubercular  broncho-pneumonia  so  closely  that  a  differ- 
ential diagnosis  between  the  two  diseases  cannot  be  made  until  after 
death,  and  even  then  the  post-mortem  appearances  may  not  be  those 
distinctive  of  tubercular  disease,  and  the  pathological  diagnosis  can  be 
determined  only  by  finding  the  tubercle  bacillus.  Children  may  be  at- 
tacked with  cough,  a  heightened  temperature,  and  the  physical  signs  of 
broncho-pneumonia.  These  signs,  as  would  naturally  be  expected,  are 
usually  found  in  the  back  and  lower  portion  of  the  lung  rather  than  at 
the  apices,  as  in  adults,  on  account  of  the  usual  nidus  of  the  tubercular 
lesions, — namely,  the  bronchial  lymph-nodes.  In  some  cases  the  onset 
of  the  disease  is  not  so  acute,  and  its  course  not  so  rapid.  The  child 
emaciates  and  has  only  a  moderate  temperature,  but  later  the  develop- 
ment of  such  symptoms  as  sweatmg,  chills,  and  hectic  fever,  together  with 
the  signs  of  softening  and  breaking  down  of  the  lung-tissue,  leads  us  to 
suspect  that  we  are  dealing  with  tuberculosis  of  the  lung. 

Diagnosis. — ^The  diagnosis,  as  a  rule,  is  to  be  made  by  taking  into 
consideration  the  family  history  of  the  child,  as  the  tissues  of  children 
whose  parents  are  tubercular  show  an  especial  liability  to  infection  by 
the  tubercle  bacillus.  Careful  investigation  should  be  made  as  to  whether 
the  child  has  been  exposed  to  tuberculosis  in  any  form  :  whether  it  has 
itself  shown  signs  of  any  localized  form  of  tuberculosis ;  and  especially 
whether  it  has  recently  had  an  attack  of  measles  or  pertussis.  The 
physical  signs  are  in  no  way  characteristic,  as  they  may  not  only  be  simi- 
lar to  those  of  the  non-tubercular  form  of  broncho-pneumonia,  but  also 
we  must  remember  that  the  various  local  conditions  of  chronic  mterstitial 
pneumonia  and  persistent  broncho-pneumonia,  although  simulating  tuber- 
cular disease,  may  in  children  be  non-tubercular.  Continuous  fever  of  a 
rather  high  grade  in  comparison  with  the  non-tulDercular  pneumonia,  the 
greater  mtensity  of  the  anaemia,  and  emaciation  mark  the  tubercular  inva- 
'"sTon.  When  the  symptoms  develop  insidiously,  especially  following  measles 
and  pertussis,  instead  of  beginning  during  the  course  of  these  diseases, 
tuberculosis  is  probable.-  It  must,  however,  be  remembered  that  simple 
non-tubercular  processes  may  last  for  many  months,  and  the  children 
finally  recover.  The  diagnosis  can  be  made  positively  only  in  those  cases 
in  which  a  specimen  of  the  sputum  can  be  obtained  and  examined  for  the 
tubercle  bacillus. 

Prognosis. — The  prognosis  is  invariably  unfavorable. 

Treatment. — The  treatment  of  tubercular  broncho-pneumonia  is  the 
same  as  that  of  the  non-tubercular  forms  (page  701). 

(3)    CHRONIC   TUBERCULOSIS  OF  THE  LUNGS. 
Chronic  Diffuse  Tuberculosis. — Chronic  tuberculosis  of  the  lungs  as 
it  is   ordinarily  met  Avith   in  adults  is   rarely  seen  in  young  children. 


SPECIFIC    INFECTIOUS    DISEASES.  391 

During  the  first  three  months  of  Kfe  tubercular  disease  of  any  form  is 
very  rare,  but  in  the  latter  part  of  the  first  year  it  becomes  very  common. 
The  tubercular  lesions  which  are  found  in  the  lungs  in  later  life  also  occur 
in  early  life.  Although  cavities  are  not  so  commonly  found  in  young 
children  as  in  adults,  it  is  not  so  much  that  they  do  not  exist,  but  because 
they  are  located  at  the  root  and  central  portions  of  the  lung,  and  are, 
therefore,  more  difficult  to  detect  on  physical  examination.  It  has  been 
noticed  that  large  cavities  at  the  apex  of  the  lung  are  rare  in  early  life, 
but  become  more  common  as  the  child  grows  older.  Tubercular  disease 
of  the  lung  is  very  irregular  in  the  extension  of  its  lesions  in  young  chil- 
dren. Much  more  advanced  lesions  are  usually  found  at  the  post-mortem 
examination  than  are  detected  during  hfe.  The  primary  lesion  of  chronic 
tuberculosis  of  the  lungs  is  commonly  a  tubercular  broncho-pneumonia. 

Chronic  Localized  Tuberculosis. — In  this  form,  from  a  single  tuber- 
cular focus,  there  is  an  extension  of  the  disease  by  continuity.  The 
bacilli  find  their  way  into  the  surrounding  lung-tissue  by  means  of  the 
lymphatics,  or  by  means  of  the  infection  of  the  adjoining  alveoli.  Nodules 
varying  in  size  may  be  produced.  In  this  form  of  localized  tuberculosis 
there  seems  to  be  a  high  resistance  of  the  tissue  to  the  tubercle  bacillus, 
and  there  is  not  the  same  tendency  to  an  extension  of  the  infection  as 
in  the  other  forms.  After  undergoing  caseation  the  tissues  seldom  remain 
in  this  condition,  for  the  caseous  material  tends  to  soften,  and  is  discharged 
by  means  of  the  bronchi,  or  it  may  be  partly  absorbed,  leaving  a  cavity 
in  its  place. 

Symptoms. — The  symptoms  of  chronic  tuberculosis  of  the  lungs  differ 
but  little  in  the  child  from  those  seen  in  the  adult,  and  are  marked  by 
the  same  irregularities  in  their  course.  This  is  due  to  the  varied  forms  of 
the  lesions.  In  young  infants  the  symptoms  are  so  often  obscure  and  the 
physical  signs  of  the  serious  pathological  conditions  which  exist  in  the 
lungs  are  so  frequently  masked  that  the  diagnosis  is  apt  to  be  very  doubt- 
ful. There  is  often  a  history  of  tuberculosis  in  the  parents.  The  more 
common  symptoms  of  chronic  tuberculosis  of  the  lungs  are  gradual  loss 
in  weight,  strength,  and  appetite,  irregular  and  moderate  hectic  fever,  and 
sweating.  The  physical  signs  are  slowly  increasing  dulness  in  certain 
areas  of  the  lung,  especially  in  the  back,  accompanied  by  rales  and  the 
other  signs  of  solidification.  Later  in  the  disease  the  characteristic  signs 
of  cavities  may  develop.  Cough  is  usually  present,  although  it  is  sometimes 
so  slight  in  the  beginning  as  not  to  be  especially  noticed  by  the  parents. 
Hsemoptysis  is  rare  in  infants  and  in  young  children,  but  may  be  present 
in  older  children  as  they  approach  the  age  of  puberty.  As  the  disease 
progresses  there  is  dyspnoea,  usually  of  a  moderate  grade,  with  cyanosis, 
but  in  some  cases  considerable  destruction  may  have  taken  place  in  the 
lung-tissue  without  the  presence  of  any  especial  dyspnoea. 

The  course  of  chronic  tuberculosis  of  the  lungs  is  rather  more  rapid 
in  children  than  in  adults,  and  it  is  seldom  that  the  long-protracted  course 


392  PEDIATRICS. 

of  the  disease  so  ft-equent  in  adults  is  met  witli  in  diildren.  Soiiietimes, 
however,  the  child  improves  in  its  general  health  and  may  live  for  many 
yeare.  In  these  cases  the  terminal  phalanges  of  the  fingers  may  become 
clubbed,  and  there  is  usually  dyspnoea  on  exertion. 

Diagnosis. — The  diagnosis  is  to  be  made  from  chronic  empyema  and 
fi^-om  chronic  non-tubercular  broncho-pneumonia.  The  former  disease 
can  be  readily  eliminated  by  making  an  exploratory  aspiration,  but  the 
latter  can  often  be  distinguished  only  by  means  of  a  bacteriological  exam- 
ination. In  older  children,  from  whom  a  specimen  of  the  sputum  can 
be  obtained,  the  diagnosis  is  readily  made  by  the  detection  of  the  tubercle 
bacillus.  In  younger  children,  in  whom  expectoration  does  not  take 
place,  the  diagnosis  is  much  more  difficult,  but  if  the  children  are  care- 
fully watched  it  is  often  possible  to  obtain  a  specimen  of  the  sputum  if 
the  child  happens  to  vomit,  in  which  case  particles  of  sputum  may  be 
coughed  up  with  the  vomitus  and  can  be  separated  from  it  and  examined. 

Prognosis.— The  prognosis  of  chronic  tulDerculosis  of  the  lungs  when 
the  symptoms  are  at  all  advanced  is  ven'  unfavorable,  but  the  post-mortem 
examinations  of  so  many  individuals  who  have  died  of  non-tubercular 
diseases  show  the  presence  of  old  tubercular  lesions  which  have  ap- 
parently ceased  to  be  of  grave  import,  that  we  must  acknowledge  that  it 
is  possible  for  many  cases  to  survive  the  invasion  of  the  disease. 

Treatment. — The  treatment  of  chronic  tuberculosis  of  the  lungs  is 
essentially  clmiatic,  and  the  children  should  be  removed  at  once,  if  possi- 
ble, from  a  climate  where  the  altitude  is  low  and  the  atmosphere  damp 
and  subject  to  great  variations.  Too  high  altitudes  are  also  to  be  avoided. 
"When  the  child  cannot  be  removed  to  a  more  favorable  locality,  strict 
attention  to  its  general  hygiene  and  to  its  food  will  in  some  cases  be  fol- 
lowed by  an  apparent  arrest  of  the  tubercular  process. 

The  treatment  of  chronic  pulmonary  tu]3erculosis  especially  calls  for 
fresh  air  and  sunshine.  The  food  should  be  given  at  regular  intervals  five 
_or  six  times  in  the  tw^enty-four  hours,  and  should  be  adapted  to  the  di- 
gestion of  the  especial  case.  There  are  no  drugs  which  are  of  much 
value  in  tliis  disease.  Cod-liver  oil  is  commonly  given,  and  in  many 
cases  seems  to  be  tolerated  by  the  stomach,  and  to  be  even  agreeable  to 
the  child.  In  our  experience,  however,  pasteurized  twenty-four  per  cent. 
cream  with  five  per  cent,  lime-water  is  equally  efficacious,  and  to  most 
children  much  less  distasteful.  When  the  appetite  is  poor  a  nerve 
tonic,  such  as  tincture  of  nux  vomica,  is  often  found  to  be  beneficial,  and 
when  there  is  considerable  anaemia  the  tartrate  of  iron  and  potash  is 
indicated. 

The  following  case  (Fig.  101,  p.  393),  illustrates  chronic  tuberculosis  of 
the  lung  following  an  acute  infectious  disease  : 

A  girl,  eiglit  years  old.  liad  a  liistory  of  tuberculosis  in  her  family.  She  had  an 
attack  of  pertussis  when  she  was  six  years  old,  and  some  months  later  an  attack  of 
measles.     Following  the  attack   of  measles  she  began  to  have  headache,   cough   and 


SPECIFIC    INFECTIOUS    DISEASES. 


393 


expectoration.      She  complained  of  pain  in  her  chest  and  abdomen,  and  of  chilly  sen- 
sations,   and    progressively  lost    in   weisfht    and    strength.      A    physical    examination 

Fm.  101. 


Chronic  tuberculosis  of  the  lung.    Female,  «  years  old. 
showed  the  skin  to  be  dry  and  ha,rsh  and  the  heart  normal.      The  left  lung  in  front 
appeared  to  be  normal.      Behind  over  a  small  area  at  the  upper  part  of  the  lung  there 

CHART  6. 


Days  of  Disease 

in. 

c. 

107° 
106° 
105° 
104 
103° 
102° 
101° 
100° 
99° 

TEMP.  ^ 

98 

97° 

96° 
95° 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

M  E 

ME 

ME 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 
35.0° 



/ 

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1 

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1 

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/ 

/ 

/ 

/ 

/ 

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/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

\ 

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/ 

AJ 

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1/ 

1 

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/ 

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1 

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Chronic  tuberculosis  of  the  lung. 

were  dulness,  broncho-vesicular  breathing,  and  some  fine  moist  rales.      Over  the  right 
upper  lobe  in  front  and  behind  there  was  dulness,  and  the   expiration  was  prolonged 


394  PEDIATRICS. 

and  hiirh-pitchod.  Over  the  dull  region  were  heard  nicdiuiu  and  fine  moist  rales. 
The  borders  of  the  areas  of  dulness  are  indicated  by  black  lines,  and  the  rales  by 
black  spots.  The  area  of  cardiac  dulness.  the  lower  part  of  the  sternum,  and  the 
lower  border  of  the  ribs  are  indicated  by  dark  lines,  and  the  edge  of  the  liver,  which 
seemed  to  be  somewhat  enlarged,  by  an  interrupted  line. 

The  chart  shows  the  irregular  temperature  which  is  commonly  seen  in  cases  of 
chronic  tuberculosis  of  the  lungs,  and  is  of  the  remittent  type. 

The  child  was  gradually  failing  and  the  signs  of  disorganization  of  the  lung  were 
slowly  progressing. 

TUBERCULOSIS   OF  THE  PLEURA. 

Tuberculosis  of  the  pleura  is  a  common  aftection  in  general  tubercu- 
losis and  in  tulDerculosis  of  the  lungs.  The  symptoms  and  treatment  do 
not  differ  from  non-tubercular  pleuritis.  but  hemorrhagic  exudations  are 
rare  in  early  childhood. 

TUBERCULOSIS  OF  THE  GASTRO-ENTERIC  TRACT. — Tuber- 
culosis of  the  gastro-enteric  tract  occurs  most  often  in  connection  with 
and  following  tuberculosis  of  the  lungs,  the  infection  being  due  to  the 
s^vallo^^"ing  of  sputum  containing  the  tubercle  bacillus.  In  rare  cases  the 
bacilli  may  find  their  entrance  in  milk  or  through  food.  Tuberculosis  of 
the  oesophagus,  stomach,  and  duodenum  is  exceedingly  rare.  The  oesoph- 
agus probably  escapes  infection  owmg  to  the  fact  that  the  sputum  con- 
taining the  bacilli  remains  for  so  short  a  time  in  contact  with  its  walls. 
which  are  also  protected  by  their  many  layers  of  epithelium.  The 
stomach  probably  owes  its  protection  to  the  presence  of  the  gastric  juice. 

TUBERCULAR  ILEO-COLrnS. 

Etiology. — Tuberculosis  of  the  intestine  is  not  so  common  in  infancy 
as  in  older  children.  In  the  latter,  however,  it  is  met  with  quite  com- 
monly, especially  in  the  middle  period  of  childhood.  The  disease  may  be 
primary  in  the  intestine,  but  this  is  very  rare.  At  the  Boston  Children's 
Hospital  we  have  had  one  case  in  which  the  tubercular  lesions  were  con- 
fined to  the  intestine  and  to  the  mesenteric  nodes.  In  this  case  Professor 
Councilman  considered  that  the  evidence  was  in  favor  of  the  intestinal 
tubercle  antedating  the  tubercle  of  the  nodes.  In  the  great  majority  of 
cases  tubercular  ileo- colitis  is  secondary  to  tuberculosis  elsewhere,  and  in 
such  cases  is  followed  by  tuberculosis  of  the  mesenteric  glands.  The 
most  common  source  of  infection,  however,  in  all  parts  of  the  gastro- 
enteric tract,  is  from  the  lung,  by  means  of  the  sputum  which  has  been 
swallowed. 

Pathological  Anatomy. — The  tubercular  lesions  are  most  common  at 
the  lower  end  of  the  ileum,  next  in  the  rectum,  and  then  in  the  colon.  In 
tuberculosis  of  the  intestine  the  corresponding  lymph-nodes  are  always 
affected.  The  tubercular  lesions  almost  invariably  occur  in  the  form  of 
ulcerations.  These  ulcers  begin  both  in  the  solitary  follicles  and  in  Peyer's 
patches.  The  ulcers  in  the  solitary  follicles  are  small.  In  Peyer's  patches 
they  may  be  large,  invohing  the  entire  extent  of  the  patch.    They  also  show 


Ftg.  102. 


Fig.  103. 
I. 


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Tubercular  ulcers  of  colon.  Female,  8J^  years 
old.  Maseum  of  the  College  of  Physicians  and  Sur- 
geons, New  York 


Tubercular  ulcers  of  small  intestine.  Female 
2%  years  old.  Museum  of  the  College  of  Physi- 
cians and  Surgeons,  New  Yoi'k. 


Large  tubercular  ulcer  of  caecum. 


SPECIFIC  INFECTIOUS  DISEASES.  395 

a  tendency  to  grow,  in  the  direction  of  the  lymphatics,  so  that  an  ulcer 
may  extend  around  the  entire  circumference  of  the  intestine.  The  tuber- 
cular ulcer  has  the  following  characteristics  :  in  contradistinction  to  the 
typhoidal  ulcer,  the  long  diameter  of  which  coincides  with  the  long  axis 
of  the  intestine,  the  tubercular  ulcer  is  transverse  to  the  long  axis,  rarely 
ovoid,  and  often  irregular  in  outline.  The  edges  overhang  and  the  base 
is  infiltrated,  and  in  many  instances  small  tubercles  may  be  visible  to  the 
unaided  eye  on  the  peritoneal  surface  at  the  base  of  the  ulcer. 

Fig.  102  represents  a  specimen  of  tubercular  disease  of  the  intestine 
which  occurred  in  the  practice  of  Dr.  Northrup. 

A  girl  eight  and  a  half  years  old  was  attacked  two  months  before  her  death  with 
chills,  fever,  and  prostration.  The  temperature  at  first  varied  from  38.8°  to  39.4°  C, 
(102°  to  103°  F.),  but  as  the  disease  progressed  the  temperature  gradually  fell.  There 
was  rapid  emaciation,  the  abdomen  was  sunken  at  first,  but  later  became  tense. 
There  were  pain,  tenderness,  and  resistance  in  the  right  inguinal  region.  The  sub- 
maxillary, cervical,  and  inguinal  lymph-nodes  were  enlarged.  The  urine  contained 
albumin  and  hyaline  casts.  There  was  diarrhoea.  The  autopsy  showed  the  lungs  to 
be  normal.  The  bronchial  and  retro-peritoneal  lymph-glands  were  enlarged  and 
cheesy.  The  colon  showed  two  large  sloughing  ulcers,  one  in  the  region  of  the  ctecum 
and  the  other  in  the  ascending  portion.  They  were  transverse  to  the  axis  of  the  colon, 
and  their  edges  were  overhanging.  The  entire  membrane  Avas  thickened,  and  there 
was  some  follicular  ulceration. 

Fig.  103,  I.  and  II.,  represent  portions  of  intestine  taken  from  a  girl  two  years  and 
eight  months  old.  She  had  had  diarrhcea  occasionally  for  a  year  and  also  convulsions. 
She  died  soon  after  entering  the  hospital.  The  autopsy  showed  extensive  ulcerations  in 
the  small  intestine  (I.),  and  a  large  ulcer  in  the  caecum  (II.).  There  were  tubercular 
ulcers  in  the  middle  third  of  the  colon.  The  peritoneal  surface  showed  miliary  tuber- 
cles.   The  mesenteric  and  bronchial  lymph-glands  were  markedly  enlarged  and  cheesy. 

Symptoms. — The  symptoms  of  tubercular  ileo-colitis  are  varied  and  in- 
definite. The  most  common  symptom  is  a  persistent  diarrhoea.  The 
diarrhoea,  however,  does  not  correspond  to  the  extent  of  the  lesions,  as 
large  ulcers  may  exist  and  constipation  be  present,  especially  if  they  are 
in  the  ileum. 

Diagnosis. — In  cases  of  primary  tuberculosis  of  the  intestine,  the  only 
certain  means  of  determining  the  tubercular  character  of  the  disease  is  to 
find  the  tubercle  bacillus  in  the  discharges.  When  the  disease  is  second- 
ary to  tuberculosis  elsewhere,  the  tubercular  involvement  of  the  intestine 
may  be  suspected,  when  at  any  time  during  the  course  of  the  disease  the 
infant  is  attacked  with  diarrhoea  of  an  obstinate  nature.  In  these  cases  the 
disease  can  only  be  established  by  finding  the  tubercle  bacillus  in  the  dis- 
charges. It  is  exceedingly  difficult  to  do  this  when  the  stools  are  watery. 
It  has  been  suggested  that  in  order  to  simplify  the  search  for  the  specific 
organism,  sufficient  opium  sliould  be  given  to  produce  a  constipated  move- 
ment, so  that  the  smears  may  be  taken  from  the  mucus  which  is  scraped 
from  the  tubercular  ulcers  and  clings  to-  the  hard  faecal  masses  as  they 
pa^s  dow^nward  along  the  course  of  the  intestine. 


396  PEDIATRICS. 

The  differential  diagnosis  is  lo  be  made  from  chronic  non-tubercular 
infectious  diarrhoea.  In  the  latter  condition  the  history  usually  shows  tliat 
the  disease  has  begun  with  an  acute  attack,  while  in  tuberculosis  the 
onset  has  been  insidious.  Markedly  enlarged  mesenteric  nodes  and  the 
evidence  of  tuberculosis  elsewhere  are  important  as  indicating  a  tubercular 
cause  for  the  intestinal  symptoms. 

Prognosis. — The  prognosis  is  very  unfavorable,  and  death  may  occur 
either  from  the  severity  of  the  intestinal  symptoms,  or,  more  rarely,  by 
perforation  or  hemorrhage.  The  prognosis,  however,  largely  depends  on 
that  of  the  tubercular  disease  to  which  the  intestinal  tuberculosis  is  sec- 
ondary. 

Treatment. — The  treatment  is  the  same  as  that  described  for  non^ 
tubercular  infectious  diarrhoea  on  page  823. 

TUBERCULOSIS    OF    THE    PERITONEUM. 

Tuberculosis  of  the  peritoneum  may  occur  in  both  infants  and  chil- 
dren, but  a  marked  inflammatory  condition,  either  with  or  without  ascites, 
is  more  common  in  children  than  in  infants.  In  infants  it  is  more  com- 
mon to  have  a  miliary  tuberculosis  of  the  peritoneum  in  the  course  of  a 
general  tuberculosis  which  does  not,  as  a  rule,  show  abdominal  symptoms. 
In  children  the  peritoneal  inflammation  may  be  so  markedly  localized  as 
to  constitute  a  disease  of  itself,  tubercular  peritonitis. 

Etiology. — The  original  source  of  the  tubercular  process  is  often  ob- 
scure. It  may  be  a  primary  infection  of  the  peritoneum,  but  most  com- 
monly is  secondary  to  tuberculosis  of  the  mesenteric  nodes.  It  may  also 
be  secondary  to  tuberculosis  of  the  intestine,  lungs,  lymph-nodes  in  vari- 
ous parts  of  the  body,  and  other  organs.  It  may  arise  in  the  course  of 
the  various  infectious  diseases,  especially  the  exanthemata.  Tubercular 
peritonitis  may  be  acute  or  chronic,  but  the  most  common  form  met  with 
in  children,  and  the  one  which  usually  represents  the  disease  clinically  is 
the  chronic. 

Pathological  Anatomy. — The  process  consists  in  the  formation  of  mili- 
ary tubercles  on  the  peritoneal  surface,  which  give  rise  to  opaque  cheesy 
thickenings,  often  nodular,  with  firm  adhesions  of  the  adjacent  surfaces. 
An  exudation  into  the  peritoneal  cavity  is  usually  present,  the  c{uantity 
generally  being  considerable  and  sero-purulent  in  character.  The  ascites 
may,  however,  be  purulent,  or  merely  serous. 

The  disease  may  occur  in  three  forms.  (1)  A  miliary  tuberculosis 
with  ascites  acute  or  subacute  in  its  course.  (2)  A  fibrous  form  in  which 
ascites  may  be,  but  is  not  usually,  present.  This  form  is  essentially 
chronic.  There  is  a  formation  of  a  fibrous  tissue  with  matting  of  the 
intestine,  of  the  omentum  and  mesentery,  and  not  much  tendency  to 
caseation  or  breaking  down.  (3)  An  ulcerative  form,  which  is  a  later 
stage  of  the  two  forms  just  described,  and  in  which  occur  large  tubercular 
deposits  with  caseation  and  softening.     The  lungs  in  this  form  are  affected. 


SPECIFIC    INFECTIOUS    DISEASES.  397 

It  is  not  so  chronic  as  the  fibrous  form  (2),  but  it  is  characterized  by  more 
fever  and  more  severe  symptoms. 

Symptoms. — The  symptoms  of  tubercular  peritonitis  vary  according  to 
the  extent  and  character  of  the  lesions.  When  they  consist  of  a  miliary 
tuberculosis  of  the  peritoneum,  with  only  a  slight  inflammatory  condition, 
they  are  usually  secondary  to  a  general  tuberculosis,  and  the  abdominal 
symptoms  are  insignificant.  When  this  form  occurs  in  young  infants  the 
later  manifestations  of  abdominal  disease  are  seldom  seen,  as  the  infant 
usually  succumbs  to  the  infection  before  the  symptoms  have  had  time  to 
develop.  When  the  disease  is  acute,  the  symptoms,  as  a  rule,  develop 
in  connection  with,  or  most  often  following,  the  symptoms  of  tuberculosis 
elsewhere,  especially  in  the  lung,  and  do  not  differ  materially  from  those 
of  acute  non-tubercular  peritonitis.  When  the  disease  is  of  the  subacute 
and  chronic  form  the  symptoms  vary  according  to  the  presence  or  ab- 
sence of  ascites  as  a  prominent  condition.  Here,  again,  the  symptoms 
correspond  to  the  character  of  the  lesions.  In  either  case  a  tubercular 
process  is  going  on,  but  in  one  it  results  in  a  large  effusion  of  fluid,  while 
in  the  other  the  more  advanced  tubercular  lesions  develop  with  no  fluid 
at  all,  or  with  only  a  small  amount. 

The  initial  symptoms  of  tubercular  peritonitis,  with  gradual  develop- 
ment of  ascites,  are  usually  ill  defined.  There  is  a  gradual  loss  of  appe- 
tite and  flesh,  with  occasional  abdominal  pain,  which,  as  a  rule,  is  not 
severe  in  character.  There  is  seldom  any  tenderness  of,  the  abdomen. 
Vomiting  is  not  a  marked  symptom.  Attacks  of  diarrhoea  are  common 
and  are  apt  to  be  paroxysmal.  There  may  be  constipation.  The  tem- 
perature is  at  times  raised,  especially  in  the  latter  part  of  the  day,  but,  as 
a  rule,  is  moderate,— 37.2°  to  38.8°  C.  (99°  to  102°  F.),— and  maybe  so 
nearly  normal  as  to  simulate  ascites  due  to  obstruction.  After  these  gen- 
eral symptoms  have  lasted  for  a  number  of  weeks,  the  abdomen  is 
noticed  to  be  distended.  A  physical  examination  may  show  that  there  is 
nothing  abnormal  in  the  thorax,  and  that  the  morbid  condition  is  confined 
entirely  to  the  abdomen.  At  first  the  abdomen  is  resonant  on  percus- 
sion, but  later  fluctuation  is  detected.  While  for  a  time  there  is  reso- 
nance in  the  region  of  the  umbilicus  when  the  child  is  lying  on  its  back, 
and  a  change  in  the  area  of  resonance  with  a  change  of  position,  this  area 
of  resonance  gradually  grows  less.  The  fluid,  however,  may  be  encapsu- 
lated by  adhesions  and  thus  the  area  of  dulness  and  resonance  be  less 
distinctly  followed.  As  the  disease  progresses  and  the  fluid  increases,  the 
whole  abdomen  becomes  much  distended  and  tense,  the  abdominal  veins 
prominent,  and  the  dulness  and  fluctuation  diminished.  In  this  higher 
grade  of  ascites  the  umbiUcus  is  at  times  found  to  be  pushed  out  by  the 
fluid. 

Clinically  separated  from  the  class  of  cases  with  ascites  as  the  promi- 
nent symptom,  are  the  still  more  chronic  cases  in  which  ascites  is  not 
prominent,  but  in  which  there  are  tubercular  processes  which,  because  of 


398  PEDIATRICS. 

certain  mechanical  conditions,  result  in  a  sot  of  symptoms  induced  by 
pressure,  such  as  oedema,  digestive  disturbance,  and  renal  congestion.  The 
general  symptoms  are  about  the  same  as  in  the  ascitic  form  just  de- 
scribed, the  difference  being  in  the  conditions  found  on  examining  the 
abdomen.  Possibly  the  onset  is  still  more  insidious  than  in  the  other 
form,  and  the  temperature  more  likely  to  be  normal.  The  abdomen 
may  be  distended  and  tympanitic,  or,  again,  varying  areas  of  dulness 
may  be  detected,  depending  usually  on  tuberculous  masses  or  tubercu- 
lous thickening  of  the  greater  omentum.  There  may  at  times  be  a  cer- 
tain amount  of  fluid  which  can  be  detected  by  fluctuation  and  change  of 
position.  Although  there  may  be  abdominal  pain  and  tenderness,  yet 
usually  these  symptoms  are  absent,  and  sometimes  markedly  so,  even 
when  the  process  has  gone  on  to  a  purulent  ascites. 

The  cases  in  which  the  more  advanced  tubercular  lesions,  such  as 
ulceration  and  breaking  down  of  the  tubercular  growths,  have  taken 
place  are  usually  secondary  to  advanced  lesions  elsewhere,  as  in  the  lung, 
and  do  not  properly  constitute  a  localized  tubercular  disease.  In  these 
cases,  however,  the  temperature  is  raised,  a  hectic  condition  is  commonly 
present,  the  wasting  is  extreme,  and  all  the  symptoms  irregular,  so  that 
wiien  these  symptoms  become  marked  in  the  other  forms  of  tubercular 
peritonitis  just  described,  the  presence  of  a  general  tuberculosis  should  at 
once  be  thought  of. 

Diagnosis. — In  a  case  in  which  the  symptoms  which  have  just  been 
mentioned  are  present  the  diagnosis  is  not  difficult.  Occasionally,  how- 
ever, there  are  no  definite  signs  by  which  a  diagnosis  can  be  made,  the 
only  tangible  sign  being  a  seeming  abdominal  tumor,  the  resemblance  of 
which  to  other  abdominal  tumors  is  so  close  that  the  diagnosis  can  only 
be  made  by  laparotomy.  We  should  remember,  however,  that  most  cases 
of  doubtful  abdominal  tumors  in  children  are  tuberculous.  In  a  case  in 
which  there  is  considerable  ascites,  it  should  be  recognized  that  while 
the  most  frequent  form  of  ascites  in  adults  is  obstruction  of  the  portal 
~  circulation,  as  in  cirrhosis,  in  young  children,  on  the  contrary,  portal  ob- 
struction is  rare,  while  ascites  from  tubercular  peritonitis  is  exceedingly 
common,  and  is  the  disease  which  should  at  first  be  thought  of.  The 
greatest  difficulty  arises  in  differentiating  simple  non-tubercular  peritonitis 
with  ascites  from  the  tubercular  form.  It  is  often  impossible  to  do  this 
without  an  exploratory  paracentesis.  If,  however,  there  is  evidence  of 
tuberculosis  elsewhere,  or  if  the  fluid  is  encapsulated,  or  if  there  is  con- 
siderable fever,  the  process  is  most  likely  to  be  tubercular.  In  the  cases 
of  tubercular  peritonitis  where  there  are  tubercular  lymph-nodes  without 
ascites,  the  diagnosis  can  only  be  made  if  irregular  masses  can  be  detected 
in  the  abdomen,  accompanied  by  fever,  wasting,  and  possibly  some  ab- 
dominal tenderness  not  accounted  for  by  disease  elsewhere.  If  tubercular 
disease  is  detected  in  the  lungs,  the  diagnosis  is  still  more  assured.  In 
many  cases,  however,  the  diagnosis  can  only  be  made  by  abdominal  para- 


SPECIFIC    IXFECTIOUS    DISEASES.  399 

centesis.  The  diagnosis  of  the  advanced  cases,  in  which  ulceration  has 
taken  place,  is  usually  to  be  made  as  part  of  a  tubercular  condition  of 
other  organs,  especially  the  lung. 

Prognosis. — When  tubercular  lesions  of  other  organs  are  present  the 
prognosis  is  bad.  In  those  cases  in  which  the  tuberculosis  is  apparently 
confined  to  the  abdomen,  the  prognosis  has  been  much  improved  since 
the  employment  of  laparotomy  for  treatment.  Any  of  these  cases  may, 
however,  eventually  die  from  a  later  infection,  as  of  the  brain  or  lung. 
When  untreated  the  prognosis  of  tubercular  peritonitis  is  very  variable. 
In  some  cases  the  disease  after  a  number  of  months  retrogrades  and  the 
patient  recovers.  In  most  instances  the  child  becomes  more  and  more 
wasted,  the  fever  becomes  more  pronounced,  the  diarrhoea  continues,  the 
emaciation  becomes  extreme,  and  the  child  dies  usually  of  exhaustion. 
The  surgical  treatment  of  the  disease  has  made  the  prognosis  much  more 
favorable. 

Treatment. — The  general  treatment  of  tubercular  peritonitis  does  not 
differ  from  that  of  the  non-tubercular  form  (see  pag-e  843).  The  essential 
treatment,  however,  in  the  cases  ^vhich  are  supposed  to  be  localized  is 
surgical,  especially  when  there  is  ascites  of  any  amount.  In  some  cases 
opening  the  abdomen  and  evacuating  the  fluid  will  not  only  give  relief, 
but  will  produce  a  permanent  cure.  In  my  experience  at  the  Boston 
Children's  Hospital  thi-  procedure  has  been  in  a  large  number  of  cases 
folloAved  by  a  complete  arrest  of  the  disease.  Cases  of  marked  tuber- 
cular peritonitis  in  whicli  laparotomy  had  been  performed,  have  been  re- 
ported as  perfectly  well  some  years  after  the  operation. 

A  case  was  that  of  a  colored  boy,  nine  years  old.  His  father  died  of  phthisis. 
The  hoy  had  never  been  strong,  but  had  suffered  no  acute  illness.  Three  weeks 
previous  to  our  seeing  him,  he  began  to  have  diarrhcea,  and  soon  after,  enlarge- 
ment of  the  abdomen.  There  was  no  pain,  vomiting,  nor  cough.  He  had  lost 
greatly  in  weight  and  Avas  much  emaciated.  His  temperature  was  38.3°  C.  (101° 
F.).  The  abdomen  was  much  distended  and  gave  a  distinct  wave  of  fluctuation. 
Physical  examination  showed  ncthing  else  abnormal. 

Laparotomy  was  performetl  and  the  fluid  evacuated.  Tubercle  bacilli  were  found 
in  the  peritoneal  tissue.  Wiien  seen  six  months  later  the  wound  had  healed  perfectly, 
and  he  was  strong  and  well 

Another  case  was  that  of  a  boy,  two  years  old.  and  is  especially  interesting  in 
regard  to  the  diagnosis. 

He  had  not  had  general  symptoms  of  serious  import,  but  had  lost  slightly  in  weight, 
appetite,  and  strength.  From  time  to  time  for  "six  months  he  complained  of  abdominal 
pain  and  tenderness.  An  examination  of  the  abdomen  showed  a  hardened,  slightly 
irregular  mass  extending  directly  across  th-e  abdomen  from  one  side  to  the  other,  5  cm. 
(2  inches)  above  and  the  same  distance  below  the  umbilicus.  It  was  not  especially 
tender  on  pressure.  Nothing  else  abnormal  was  detected  about  the  child.  The  line 
of  percussion  did  not  change  when  he  was  lying  on  his  back.  There  was  no  evidence 
of  ascites.  Laparatomy  was  performed  and  a  mass  of  cheesy  nodules  matting  together 
the  intestine  was  found.  An  examination  of  a  portion  of  this  mass  showed  the  pres- 
ence of  the  tubercle  bacillus.     Xo  fluid  was  present.     The  child  recovered. 


400  PEDIATRICS. 

The  next  case  was  that  of  a  hoy,  four  years  old,  hrought  to  the  hospital  with  the 
extreme  distention  of  the  abdomen.  A  physical  examination  showed  nothing  abnormal 
except  in  the  abdomen,  which  was  dull  on  percussion  and  showed  fluctuation  in  every 
part.  The  child  had  gradually  lost  in  weight,  appetite,  and  strength.  Laparotomy  was 
performed  and  a  large  amount  of  ascitic  fluid  evacuated.  Tubercle  bacilli  were  present 
in  the  diseased  peritoneum.  The  wound  healed,  but  in  the  course  of  a  few  weeks  the 
fluid  re-accumulated,  and  laparotomy  was  again  performed.  Some  weeks  after  the 
second  operation  no  fluid  could  be  detected.  There  was  no  recurrence  of  the  ascites, 
and  the  child  recovered  completely. 

Another  case  is  that  of  a  boy,  eleven  years  old.  He  had  been  perfectly  well  until 
four  months  before  coming  to  the  hospital,  when  he  began  to  lose  in  weight  and  appe- 
tite and  to  show  an  increase  in  the  size  of  his  abdomen.  Although  he  was  not  espe- 
cially emaciated,  he  had  lost  in  flesh  and  was  pale.  The  circumference  of  the  abdomen 
was  76.4  cm.  (30  inches).  On  physical  examination,  nothing  abnormal  was  detected 
in  any  of  the  other  organs.  For  some  months  before  the  boy  showed  peritoneal  symp- 
toms, he  had  been  drinking  the  milk  of  a  tubercular  cow.  Laparotomy  was  per- 
foi'med  and  a  large  amount  of  serous  fluid  of  a  dark  yellow  color  was  removed.  The 
peritoneum  was  found  to  be  thickly  studded  with  minute  tubercles,  and  tubercle  bacilli 
were  demonstrated.  The  peritoneal  cavity  was  irrigated  and  drained.  He  recovered 
completely  from  the  operation,  and  when  examined  four  years  later,  was  found  to  be 
well  and  strong,  and  to  show  no  signs  of  tubercular  disease. 


TUBERCULOSIS  OF  THE  CEREBRO-SPINAL  SYSTEM. — 
Tuberculosis  of  the  cerebro-spinal  system  usually  takes  the  form  of  an 
infection  of  the  meninges  (tubercular  meningitis),  and  is  found  most  com- 
monly in  the  meninges  at  the  base  of  the  brain.  As  a  rule,  the  disease  is 
never  so  extensive  in  the  spinal  as  in  the  cerebral  meninges.  Some- 
times, though  very  rarely,  a  gro\\4h  of  miliary  tubercles  in  the  meninges 
extends  into  the  tissues  of  the  brain.  The  tubercle  bacilli  themselves  are 
usually  confined  to  the  brain,  but  they  may  extend  to  the  lungs  and  pro- 
duce definite  foci  of  embolic  pneumonia. 

TUBERCULiOSIS   OF  THE  BRAIN. 

Pathological  Anatomy. — Tuberculosis  of  the  brain  may  occur  in  the 
form  of  scattered  miliary  tubercles,  or  these  tubercles  may  occur  as  nodu- 
lar masses  of  various  sizes  formed  by  aggregations  of  miliary  tubercles. 
These  nodular  masses  may  be  single,  but  are  more  commonly  multiple,  and 
are  found  in  both  the  cerebrum  and  cerebellum,  but  most  frequently  in 
the  latter.     They  are  occasionally  found  in  the  crus. 

Symptoms. — Tubercular  lesions  of  the  brain  are  always  terminal.  The 
scattered  miliary  tubercles  are  usually  a  part  of  a  general  miliary  tubercu- 
losis, and  usually  do  not  produce  any  special  cerebral  symptoms.  When, 
however,  masses  of  tubercles  large  enough  to  be  considered  tumors  are 
present,  they  present  the  symptoms  of  cerebral  tumor  as  described  on 
page  978.  In  some  cases  tubercular  tumors  of  considerable  size  have 
been  found  at  the  autopsy,  when  during  life  ho  symptoms  have  been 
noted.     Such  a  case  is  described  on  page  980. 


SPECIFIC   INFECTIOUS   DISEASES.  4(1] 

Prognosis. — Although  these  tubercular  lesions  of  the  brain  may  remain 
latent  during  long  periods,  as  a  rule  they  result  fatally,  so  that  the  prog- 
nosis is  very  bad. 

Treatment. — The  use  of  drugs  in  these  cases  is  not  of  very  much 
benefit.  Surgical  interference  lias  proved  of  value  when  we  are  assured 
that  a  tubercular  condition  is  present. 

TTTBEROULAE,  MENTNGITIS. 
Etiology. — Tubercular  meningitis  is  a  tubercular  infection  resulting  in 
an  inflammation  of  the  pia  mater.  It  is  not  a  primary  disease  of  the 
meninges,  but  is  always  a  terminal  lesion  produced  by  the  tubercle  bacillus, 
which,  originating  elsewhere,  is  carried  to  the  brain  by  the  lymphatics  or 
the  blood-vessels.  In  infants  the  tubercular  meningitis  is  usually  second- 
arj'  to  a  general  tuberculosis  or  to  tubercular  lesions  in  the  lungs.  In 
older  children  it  is  apt  to  be  secondary  to  tuberculosis  of  the  lymph- 
nodes,  bones,  or  joints.  The  tubercular  form  of  otitis  is  not  uncommon, 
and  may  be  the  starting-point  of  a  meningeal  infection.  Tubercular 
meningitis  is  the  most  common  form  of  menmgeal  disease  in  children.  It 
occurs  most  commonly  in  early  life,  runs  a  subacute  course,  and  is  invari- 
ably fatal.  It  occurs  more  commonly  between  the  ag-es  of  two  and  seven, 
than  at  any  other  period  of  life.  It  is  rare  in  the  first  year  of  life,  espe- 
cially in  the  early  months ;  the  number  of  cases  increases  rapidly  in  the 
second  year  and  decreases  as  rapidly  after  the  eighth  year.  It  is  com- 
paratively so  rare  in  adult  life  that  out  of  a  large  number  of  adult  pa- 
tients that  we  met  in  our  service  at  the  City  Hospital  only  a  few  cases  of 
tubercular  meningitis  came  under  our  care  during  a  service  of  ten  years. 
In  a  large  number  of  cases  there  is  a  tuJDercular  history  of  one  or  both 
parents. 

Pathological  Axato.mt. — A  knowledge  of  the  general  pathological  anat- 
omy of  tubercular  meningitis  is  of  great  practical  importance  in  acquiring 
a  clear  picture  of  the  disease.  Although  the  nidus  of  the  tubercle  bacillus 
which  produces  the  pathological  lesions  of  tubercular  meningitis  is  in 
some  other  part  of  the  body,  and  the  lesions  of  the  brain  and  its  meninges 
are  always  secondary,  yet,  as  the  clinical  characteristics  of  the  disease  are 
those  of  a  primary  cerebral  nature,  only  the  morbid  lesions  which  occur  in 
the  brain  will  be  described. 

The  macroscopic  pathological  condition  which  is  seen  in  the  brain  as 
a  result  of  the  action  of  the  tubercle  bacillus  is  a  growth  of  miliary  tuber- 
cle in  the  meninges.  This  growth  is  especially  marked  in  the  meshes  of 
the  pia  mater  along  the  course  of  the  blood-vessels  at  the  base  of  the 
brain.  These  small  granulations  are  conspicuously  numerous  in  the  choroid 
plexus,  and  cause  great  irritation  in  the  neighboring  parts.  The  irritation 
is  followed  by  an  exudation  of  greater  or  less  extent  into  the  ventricles. 
Accompanymg  this  there  is  also  a  fibrino-purulent  exudation  between  the 
pia  mater  and  the  cerebral  convolutions  at  the  base  of  the  brain,  notably 

26 


402  PEDIATRICS. 

in  the  fissures  of  Sylvius,  but  at  times  covering  the  whole  convexity. 
This  inflammatory  exudation  is  usually  confined  to  the  meninges,  but  it 
may  extend  into  the  tissue  of  both  brain  and  cord  and  over  the  upper 
surface  of  the  cerebellum.  A  marked  characteristic  of  the  disease,  and 
one  Avhich  tends  to  distinguish  it  from  other  forms  of  meningitis,  is  the 
extension  of  the  exudation  from  the  meninges  around  the  sheaths  of  the 
cranial  nerves.  The  nerves  apt  to  be  affected  are  the  auditory,  optic,  and 
the  fifth  nerve.  The  amount  of  exudation  is  not  proportionate  to  the 
number  of  tubercles.  The  ventricles  are  sometimes  so  distended  as  to 
burst  the  septum.  Pressure  is  thus  brought  upon  the  central  portions  of 
the  brain,  involving  especially  the  optic  thalamus,  the  corpus  striatum, 
and  the  corpus  callosum.  While  the  symptoms  vary  in  different  indi- 
viduals and  at  different  ages,  the  pathological  lesions,  on  the  other  hand, 
with  the  exception  of  their  location,  are  comparatively  stable.  What  is 
of  especial  interest  to  us  clinically,  however,  is  that,  although  in  a  typical 
case  of  tubercular  meningitis  in  middle  childhood  the  symptoms,  as  a 
rule,  correspond  to  the  pathological  lesions,  yet  in  some  cases  we  find  an 
entire  lack  of  such  symptoms  as  would  naturally  result  from  the  wide- 
spread and  prominent  lesions.  The  spinal  meninges  are  occasionally 
involved  in  tubercular  spondylitis  (Pott's  disease). 

Symptoms. — Tubercular  meningitis  presents  many  irregularities  in  its 
manifestations,  and  its  typical  symptoms  vary  according  to  the  age  of  the 
patient.  By  careful  study  of  the  pathology  of  tubercular  meningitis  we 
can  almost  deduce  the  sequence  of  symptoms  which  we  should  expect  to 
meet  with  in  the  middle  period  of  childhood,  a  period  when  the  disease  is 
seen  in  its  most  typical  form.  In  fact,  in  the  great  majority  of  cases  oc- 
curring between  the  ages  of  two  and  eight  years  this  sequence  is  very 
striking.  As  we  are  dealing  with  a  symptom  of  general  tuberculosis,  we 
should  expect  to  find  in  the  early  stages  of  the  disease  that  the  nutrition 
is  affected,  that  there  are  a  lessened  appetite,  loss  in  weight,  anaemia,  and, 
in  fact,  symptoms  which  warn  us  that  something  is  affecting  the  child's 
general  health.  This  condition  may  last  for  many  weeks,  or  even  months, 
varying  as  to  the  time  when  the  tubercle  bacillus  has  left  its  original 
nidus  and  migrated  to  the  cerebral  meninges.  Only  after  this  has  occurred 
do  we  begin  to  get  symptoms  of  cerebral  irritation.  The  child  then  be- 
comes peevish  and  capricious,  and  is  in  some  cases  easily  frightened.  As 
the  tubercular  growth  increases  and  causes  further  congestion  of  the 
blood-vessels,  the  sleep  is  disturbed ;  the  child  complains  of  dizziness  and 
slight  evanescent  pains  in  the  head ;  it  staggers  slightly  in  its  walk  (static 
ataxia) ;  sometimes  it  cries  out  sharply,  especially  at  night  (hydrocephalic 
cry).  Vomiting,  apparently  not  connected  with  the  food,  and  usually 
without  nausea,  is  a  common  symptom.  It  may  occur  only  once  or 
several  times,  or  it  may  last  for  a  number  of  days.  These  are  symptoms 
of  irritation  of  the  nervous  centres,  and  may  last  for  a  week  or  two,  ac- 
cording to  the  'development  of  the   pathological    lesions.      Progressive 


SPECIFIC   INFECTIOUS   DISEASES. 


403 


emaciation  becomes  prominent,  and  the  increasing  apatliy  is  very  notice- 
able. 

The  temperature  is  usually  moderately  raised,  37.2°-37.7°-38.3°  C. 
(99°-100°-101°  F.),  but  on  some  days  it  rises  a  degree  or  so  higher,  and 
just  before  death  a  considerable  elevation  may  occur.    Chart  7  shows  the 

CHAET    7. 


Days  of  Disease. 

h'. 

1 

2 

3 

4 

5 

6 

7       8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

c. 

107° 
106° 
105° 

104° 
103° 
102° 
101° 
100° 
99° 

NORM'L 

98'° 

97° 

96° 
95° 

MB 

ME 

ME 

ME 

ilE 

ME 

MB 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

MEl 

ME 

ME 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

372° 
370° 
36.6° 

36.1° 

35.5° 
35.0° 

/ 

/ 

s 

/ 

/ 

1 

/ 

/ 

■^ 

/ 

,/ 

/ 

l/ 

V 

u 

\/ 

/ 

/ 

l/ 

1/ 

1/ 

]/' 

u 

/ 

1/ 

V 

^ 

/ 

/... 

Y... 

L_-. 

..... 

— - 

— 

— 

Tubercular  meningitis.    Male,  4  years  old. 


temperature  of  a  child  four  years  old.  It  represents  very  well  what  will 
usually  be  met  with  in  uncomplicated  cases  of  tubercular  meningitis.  It 
is  impossible  to  determine  the  exact  day  of  the  beginning  of  the  disease  in 
such  an  affection  as  tubercular  meningitis,  so  that  the  first  day  marked  on 
the  chart  is  merely  approximate  and  serves  as  a  starting-point  to  show 
the  character  of  the  temperature.  The  pulse  at  first  is  somewhat  accel- 
erated, but  soon  becomes  slower  than  normal,  and  is  apt  to  intermit.  In 
determining  whether  the  pulse  is  slow,  the  age  of  the  child  must  be  taken 
into  consideration.  (See  page  66.)  The  respirations  may  in  the  early 
part  of  the  disease  be  quickened,  and  at  times  are  of  a  sighing  character. 
Obstinate  constipation  is  a  common  symptom.  The  urine  is  scanty. 
Hyperaesthesia  of  the  skin,  with  occasional  waves  of  congestion,  especially 
of  the  cheeks,  is  sometimes  met  with.  The  pain  in  the  head  increases, 
and  the  child  is  apt  to  hold  its  hand  to  its  head.  Drowsiness,  at  first 
slight,  soon  becomes  very  marked,  and  gradually  changes  to  stupor,  diffi- 
culty in  arousing  the  child  becoming  greater  and  greater.  The  child  is 
apathetic  and  lies  in  bed,  refusing  to  eat.  There  is  photophobia,  and  the 
pupils  may,  early  in  the  disease,  be  contracted.  Tubercles  in  the  fundus 
of  the  eye  are  rarely  seen  during  life.  The  eyes  have  a  fixed,  expression- 
less look.     Abdominal  pains  are  quite  frequent,  and  depression  of  the 


404  PEDIATRICS. 

abdomen  (boat-shaped)  is  noticed  in  a  certain  number  of  cases.  Drawing 
the  finger  over  the  skin  usually  produces  a  bright  red  line,  which  be- 
comes in  a  few  minutes,  quite  intense,  and  lasts  perhaps  ten  or  fifteen 
minutes,  which  is  much  longer  than  would  be  the  case  in  a  healthy  child. 
This  phenomenon  is  called  the  tache  cerebrale,  and  is  quite  frequently  met 
with  in  tubercular  meningitis,  although  it  may  be  absent.  This  sign  is, 
however,  in  no  sense  typical,  and  is  seen  in  a  number  of  other  diseases. 
Kernig's  sign  may  or  may  not  be  present.  The  child  at  this  stage  of  the 
disease  is  apt  to  roll  its  head  on  the  pillow  almost  continuously.  If 
diarrhoBa  appears,  we  should  suspect  tuberculosis  of  the  intestine. 

When  the  pathological  irritation  has  gone  on  to  exudation,  we  begin  to 
get  symptoms  of  pressure.  Sopor  comes  on  rapidly,  and  the  child  can  no 
longer  be  aroused.  Strabismus,  nystagmus,  and  ptosis  may  appear.  The 
pupils  are  dilated  and  irregular,  respond  slowly  to  light  and  later  not  at 
all.  The  cornea  becomes  clouded.  The  Meibomian  secretion  is  some- 
times markedly  increased.  Muscular  twitching  may  occur.  Convulsions, 
generally  partial,  and  of  a  rather  mild  type,  set  in.  Rigidity  of  the  neck 
and,  at  times,  opisthotonos  develop.  Movement  of  the  head  and  trunk  and 
pressure  over  the  spinous  processes  may  cause  pain.  At  times  paralysis 
of  the  arm,  or  of  the  arm  and  leg  (hemiplegia),  and  interference  with 
sight  (optic  neuritis),  may  be  noticed.  The  cutaneous  reflexes  are  dimin- 
ished and  the  deep  reflexes  of  the  arms  and  legs  are,  as  a  rule,  increased. 
The  paralysis  which  in  some  cases  occurs  early  in  the  disease  is  not 
necessarily  permanent.  At  this  stage  the  pulse  becomes  markedly  slow 
and  irregular,  50-60-70,  and  it  is  very  common  to  find  an  intermis- 
sion in  the  pulse,  although  this  must  not  be  considered  as  diagnostic 
of  tubercular  meningitis.  The  respirations  are  not  perceptibly  diminished 
at  first,  but  soon  become  slow,  10  to  15  in  a  minute.  A  peculiar 
form  of  respiration,  called  Cheyne-Stokes,  is  usually  seen  at  this  stage  of 
the  disease.  The  type  of  respiration  is  characterized  by  complete  or 
almost  complete  cessation  of  the  respiratory  movements  for  a  number  of 
-seconds.  This  is  followed  by  a  faint  return  of  the  respiratory  move- 
ments, Avhich  gradually  increase  in  depth,  rising  for  five  or  six  inspirations 
and  then  fading  away  again  so  as  to  be  imperceptible. 

A  heightened  temperature  in  tubercular  meningitis  indicates  a  compli- 
cation of  some  kind,  such  as  pulmonary  tuberculosis,  pneumonia,  or  tuber- 
culosis of  the  intestine.  At  the  end  of  the  disease,  however,  the  temper- 
ature rises  rapidly,  as  do  the  pulse  and  respirations.  Hearing,  taste,  and 
smell  seem  to  be  unimpared  for  some  time.  The  position  which  children 
with  tubercular  meningitis  often  take  is  somewhat  characteristic.  In  all 
forms  of  meningitis  they  are  apt  to  bury  their  heads  in  the  bedclothes, 
and  there  is  often  spasmodic  retraction  of  the  head.  They  are  inclined 
to  lie  with  their  knees  drawn  up,  and  there  may  be  spasmodic  opisthot- 
onos. A  striking  feature  which  not  infrequently  occurs  in  the  course  of 
these  general  symptoms  is  a  partial  return  to  conciousness  after  the  child 


SPECIFIC    LVFECTIOUS    DISEASES.  4O5 

has  been  lying  in  a  stupor  for  several  days.  This  jilcjuonienon  often  in- 
duces the  parents,  and  sometimes  even  the  physician,  to  entertain  hopes 
of  improvement.  It  is,  however,  always  delusive,  for  it  has  no  favorable 
significance,  and  is  soon  followed  by  a  more  profound  state  of  uncon- 
sciousness. These  symptoms  which  been  have  mentioned  do  not,  of 
course,  always  appear  together,  but  may  be  present  in  diflferent  groups, 
varying  ^vith  the  individual.    All  the  symptoms  may  chsappear  temporarily. 

The  duration  of  the  disease  varies.  It  is  usually  from  three  to  six 
weeks,  but  may  last  only  one  week,  and  again  eight  or  even  twelve  weeks. 
The  cases  of  shorter  duration  usually  present  more  active  and  severe 
symptoms,  and  ones  more  chfficult  to  differentiate  from  simple  acute 
meningitis.  Death  may  be  preceded  by  continued  convulsions  for  several 
hoiu-s,  but  usuaDy  the  pulse  becomes  weaker,  the  temperature  rises,  the 
child  can  no  longer  be  made  to  swallow,  and,  accorchng  to  Sachs,  ches 
from  paralysis  of  the  cardiac  and  respirator}^  centres. 

Infantile  Tubercular  Mening-itis. — Symptoms. — ^Accorduig  to  some 
extended  observations  made  at  the  hospital  ia  Stockliolm,  mfantile  tuber- 
cular meningitis  is  characterized  in  the  first  year  by  an  absence  of  prodro- 
mata,  the  sudden  development  of  acute  symptoms,  a  short  course,  and  a 
fatal  issue.  The  temperature  is  high, — 38.8°-39.4°-40°  C.  (102°-103°- 
104°  F.)  The  respirations  are  quickened  and  comparatively  regular. — 
30-40-50.  The  pulse  is  high, — 130-140-150.  Clonic  spasms  and 
strabismus  often  occur.  Paralysis  is  cjuite  frequent,  and  diarrhoea  is 
present  rather  than  constipation.  Bulging  of  the  fontanelles  is  usual. 
Sinking  of  the  aiDdomen  is  rare.  Vomiting  may  occur,  but  is  not  espe- 
cially common.  Sharp  cries  are  occasionally  met  with.  The  difierential 
diagnosis  from  non-tubercular  meningitis  is  difficult.  Sopor  and  coma  at 
the  end  are  frequent  in  both  diseases.  The  duration  is  seldom  more  than 
a  week.  It  may  be  only  two  days,  yet  in  rare  cases  the  mfant.  like  the 
child,  may  hve  for  a  month. 

During  the  second  year  the  symptoms  of  tubercular  menmgitis  become 
of  an  irregular  tj^e,  sometimes  assuming  the  character  of  those  which  are 
seen  in  the  first  year,  but  soon  corresponding  more  nearly  to  those  which 
are  met  with  m  the  middle  period  of  childhood. 

DLA.GX0SI5. — The  diagnosis  of  tiilDercular  meningitis  in  the  middle 
period  of  childhood,  and  with  the  sequence  of  symptoms  just  descriJDed, 
is  not  diflicult.  but  in  the  early  days,  or  even  in  the  first  week  of  the 
disease,  must  necessarily  be  very  obscure.  When  the  process  occurs  in 
young  infants  the  difficulty  is  still  greater.  It  is  by  watcliing  the  course 
of  the  disease  and  the  general  grouping  of  symptoms,  rather  than  by  the 
consideration  of  any  one  symptom,  or  even  one  group  of  symptoms,  that 
we  are  justified  in  makmg  a  definite  diagnosis.  The  diagnosis,  then,  must, 
as  a  rule,  be  held  in  abeyance  for  many  days.  Reflex  vomiting  ^Yiih  a 
moderate  temperature,  irregularity  and  intermission  of  the  pulse,  apathy, 
and  many  other  symptoms  of  tubercular  meningitis  we  have  seen  in  cases 


406  PEDIATRICS. 

in  which  there  were  no  serious  cerebral  lesions.  The  active  development 
and  sensitive  condition  of  the  nervous  system  in  children  are  so  exagger- 
ated in  comparison  with  those  of  adults,  that  whatever  condition  may  be 
present,  it  is  liable  to  produce  so  profound  an  impression  on  the  child's 
nervous  centres  that  actual  disease  of  these  centres  is  readily  simulated. 
Thus,  for  days  symptoms  apparently  cerebral  may  mask  by  their  undue 
prominence  the  presence  of  the  real  disease. 

As  a  rule,  in  most  cases  the  distinctive  picture  of  a  beginning  tuber- 
cular meningitis  after  the  first  year  of  life  closely  simulates  that  of  a  simple 
digestive  attack.  Reflex  vomiting,  continued  for  some  time  without  ade- 
quate explanation,  and  progressive  loss  in  weight  and  strength,  with 
change  in  temperament,  should  awaken  suspicion  of  the  more  serious 
disease.  Marked  constipation,  apathy,  and  drowsiness,  slowly  increasing 
stupor,  and  slow,  irregular  pulse  and  respiration,  with  a  moderate  tem- 
perature, will  strengthen  the  diagnosis.  Confirmatory  evidence  of  the 
presence  of  tubercular  meningitis  can  be  obtained  in  many  cases  by  means 
of  lumbar  puncture.  The  differential  diagnosis  from  other  diseases  and 
the  presence  of  some  form  of  meningitis  can  readily  be  made  by  the 
cerebro-spinal  fluid,  which  contains  some  form  of  pathogenic  organism 
and  is  usually  cloudy.  The  cerebro-spinal  fluid  in  tubercular  meningitis 
contains  cells  which  are  essentially  lymphoid  in  character,  the  polymor- 
phonuclear leucocytes  being  much  less  numerous.  In  addition  to  this, 
the  fluid  is  less  turbid  than  in  the  other  forms  of  meningitis.  Cover-glass 
preparations,  taken  from  the  centrifugalized  sediment,  may  show  the 
tubercle  bacillus,  but  even  when  the  examination  is  negative  inoculation 
of  the  fluid  will  often  produce  tuberculosis  in  guinea-pigs. 

In  the  other  forms  of  meningitis,  including  the  epidemic  cerebro-spinal 
form,  the  cells  are  mostly  of  the  polymorphonuclear  variety,  while  the 
lymphoid  cells  are  less  numerous.  The  fluid  is  also  more  cloudy  than  in 
the  tubercular  form.  In  addition  to  this,  some  special  organism  may  be 
found,  such  as  the  pneumococcus  in  cases  of  pneumonia,  and  the  diplo- 
coccus  intracellularis  in  the  epidemic  form. 

Differential  Diagnosis. — The  differential  diagnosis  must  be  made  be- 
tween meningitis  in  general  and  other  diseases,  such  as  (1)  diseases  of  the 
stomach,  (2)  anterior  poliomyelitis,  (3)  pneumonia,  (4)  malaria,  (5)  typhoid 
fever,  (6)  syphilis,  (7)  nephritis,  (8)  epidemic  cerebro-spinal  meningitis, 
and  (9)  acute  meningitis. 

(1)  From  Diseases  of  the  Stomach. — Unless  the  child  is  very  young, 
symptoms  due  to  acute  gastric  disturbance  are,  as  a  rule,  not  difficult  to 
recognize  after  the  first  few  days.  We  may  at  times,  however,  be  sus- 
picious of  cerebral  disease  when  in  an  infant  there  is  continual  vomiting 
and  an  elevated  temperature,  in  whom  there  is  no  discoverable  source  of 
reflex  irritation  to  account  for  the  symptoms.  This  is  especially  the  case 
if  there  is  some  irregularity  of  respiration  and  the  pulse  is  slow.  These 
may  prove  to  be  cases  of  tubercular  meningitis  in  the  first  year  of  life. 


SPECIFIC   INFECTIOUS   DISEASES.  407 

Again,  however,  they  may  be  simply  cases  of  reflex  vomiting.   As  an  illustra- 
tion of  this  class  of  reflex  gastric  disturbance  the  following  case  may  be  cited: 

A  male  infant,  eight  months  old,  was  attacked  with  vomiting  which  lasted  with 
short  intervals  for  two  days.  There  was  apathy,  and  the  pulse  was  slow  and  intermit- 
tent. The  temperature  was  37.2°  C.  (99°  F.).  There  Avere  irregular  respiration  and 
rapid  emaciation.  The  patient  made  a  perfect  recovery  in  four  or  five  days,  and  the 
case  proved  to  be  one  of  cyclic  vomiting.  The  slow,  intermittent  pulse,  and  the 
moderate  temperature,  which  would  have  been  so  alai-ming  in  an  older  child,  led  us  in 
this  case,  as  in  others  in  the  fii'st  year  of  life,  to  eliminate  tubercular  meningitis.  In 
our  experience  this  interpretation  of  symptoms  has  proved  to  be  correct. 

(2)  From  Ante7%or  Poliomyelitis. — The  following  case  of  anterior  polio- 
myelitis resembled  tubercular  meningitis  : 

A  boy,  eighteen  months  old,  showed  for  over  a  week  symptoms  closely  simulating 
those  of  tubercular  meningitis.  Obstinate  constipation  and  apathy  were  present,  fol- 
lowed by  unconsciousness  ;  there  was  also  a  marked  tache  ckr'tbrale,  distended  fonta- 
nelle,  irregular  pulse,  contracted  pupils,  eyes  turned  upward,  and  convulsive  attacks. 
Finally,  paralysis  of  the  arms  appeared,  the  general  symptoms  passed  off,  and  the  diag- 
nosis of  anterior  poliomyelitis  was  readily  made. 

(3)  From  Pneumonia. — A  certain  number  of  both  primary  and 
secondary  cases  of  meningitis  have  been  proved  to  have  been  caused 
by  the  pneumococcus  lanceolatus,  but  the  number  as  yet  has  been  too  few 
to  formulate  a  symptomatology  separate  from  that  of  the  other  forms  of 
meningitis.  The  leucocytosis  is  generally  much  greater  in  pneumonia,  while 
many  cases  of  tubercular  meningitis  show  no  increase  in  the  white  corpus- 
cles. The  cases  of  pneumonia  reported  on  page  681  warn  us  that  we  should 
hold  our  diagnosis  in  abeyance  sometimes  even  for  a  w^eek,  and  that  the 
nervous  symptoms  arising  in  the  course  of  a  pneumonia  may  closely  simu- 
late those  arising  from  meningitis. 

(4)  From  Malaria. — Although  we  must  admit  that  malaria  closely  sim- 
ulates almost  any  disease,  it  is  not  usual  to  mistake  the  malaria  of  older 
children  for  tubercular  meningitis.  An  examination  of  the  blood  for  the 
presence  of  the  Plasmodium  will  generally  make  the  diagnosis  clear.  In  the 
first  two  years  of  life,  however,  malaria  may  affect  so  insidiously  the  gen- 
eral nutrition  before  its  characteristic  syn^ptoms  appear  that  some  doubt 
as  to  the  differential  diagnosis  may  arise,  as  illustrated  in  the  following  case : 

A  male  infant,  twenty  months  old,  with  a  history  of  tuberculosis  on  the  mother's 
side,  began  to  show  symptoms  of  anaemia  and  malnutrition  with  no  perceptible  cause, 
such  as  improper  food  or  bad  general  hygiene,  to  account  for  it.  After  two  or  three 
weeks  it  had  attacks  of  unconsciousness  lasting  for  hours  ;  at  other  times  drowsiness, 
with  irregular  pulse  and  respirations,  was  noticed.  The  temperature  was  39.5°  to  40° 
C.  (103°  to  104°  F.).  There  were  slight  convulsions,  and  the  fontanelles  were  dis- 
tended. At  first  there  was  no  periodicity  of  the  symptoms,  but  a  week  later  the 
attacks  were  evidently  more  pronounced  every  other  day,  while  on  the  intervening  days 
the  infant  was  brighter.  It  lived  in  a  malarial  district.  On  the  administration  of 
quinine  and  on  removing  the  infant  to  a  non-malarial  region,  these  symptoms  entirely 


408  PEDIATRICS. 

(lisappeari'd.      Tlie  flfteclioii   of  lln'   iil;isiiiiMlinm   wmilil.    of  (-(jursc,    li;i\('  di'loiiiiinMl 
the  (lingnosis  in  this  case,  Jiiit  it  could  not  Ijc  ol)tniMe(l. 

Another  case,  which  was  seen  in  consultation,  is  also  instructive  in  warn- 
ing us  to  be  careful  in  making  a  diagnosis  of  tubercular  meningitis  in  cases 
in  which  there  is  a  possibility  of  malaria  being  the  cause  of  the  symptoms. 

A  male  infant,  fourteen  months  old.  had  always  been  well  until  fourteen  days  pre- 
vious to  the  time  when  we  first  saw  it.  It  then  began  to  be  fretful  and  to  have  diarrhoea. 
This  condition  continued  for  about  a  week,  Avhen  it  fell  into  a  stupor,  became  very 
anaemic,  and  it  was  necessary  to  feed  it  by  means  of  a  dropper.  At  times  it  would  cry 
out  sharply.  The  temperature  varied  from  37.2°  to  38.7°  C.  (99°  to  102°  F.).  The 
respirations  were  usually  regular,  but  at  times  Avere  of  the  Cheyne-Stokes  type.  The 
pulse  was  about  120.  sometimes  regular,  but  at  times  intermitting.  The  pupils  were 
sometimes  contracted,  but  showed  no  irregularity.  No  otlier  abnormal  conditions  -were 
detected,  but  the  abdomen  was  depressed.     The  tache  e'erkbrale  was  very  distinct. 

On  close  inquiry  we  found  that  there  was  a  slight  periodicity  in  the  symptoms, 
shown,  by  a  rise  of  temperature  on  each  afternoon  and  followed  by  the  stupor  becoming 
somewhat  less.  Although,  the  infant  had  been  unconscious  for  a  week,  and  was  becom- 
ing weaker  and  taking  less  nourishment  every  day,  yet^  on  the  supposition  that  it  might 
possibly  be  an  obscure  case  of  malaria,  w'e  decided  that  quinine  should  be  administered 
in  suppositories.  On  the  next  day  a  slight  improvement  was  noticed  during  the  after- 
noon. The  infant  appeared  less  comatose,  but  its  temperature  and  pulse  remained  as 
on  the  previous  days.  On  the  following  day,  which  was  the  second  from  the  time  that 
it  had  begun  to  receive  the  quinine,  it  rapidly  became  conscious  and  began  to  drink 
milk.  On  the  following  day  it  was  reported  to  have  had  a  restless  night  and  two  slight 
convulsions.  Its  temperature  in  the  morning  was  38.2°  C.  (100.9°  F.),  and  the  pulse 
was  115  and  not  intermittent.  On  the  next  day  there  Avas  marked  improvement  in 
every  way,  and  this  continued  without  interruption. 

(5)  From  Typhoid  Fever. — In  our  experience  in  cases  in  which  J30sitive 
results  are  not  obtained  from  the  "Widal  reaction  and  from  lumbar  punct- 
ure, typhoid  fever  in  young  children  is  the  disease  which,  next  to  the 
non-tubercular  forms  of  meningitis,  is  most  likely  to  simulate  and  be  mis- 
taken for  tubercular  meningitis.  The  differential  diagnosis  is  given  on 
page  445.     We  may  also  have  considerable  difficulty  in  differentiating  tu- 

ercular  meningitis  from  the  non-tubercular  meningitis  which  may  occur 
in  the  course  of  typhoid  fever  ;  this  form  of  meningitis,  although  exceedingly 
rare,  may  occur,  as  has  been  proved  by  finding  the  typhoid  bacillus  in  the 
cerebro-spinal  fluid  by  lumbar  puncture.  The  extreme  cerebral  con- 
gestion which  at  times  arises  as  a  symptom  of  typhoid  fever  may  also  add 
fresh  difficulties  to  the  differential  diagnosis. 

(6)  From  Syphilis. — The  history  and  general  symptoms  of  syphilis  are 
to  be  sought  for  where  a  syphilitic  meningitis  is  suspected.  The  temperature 
is  not  especially  high,  and  the  symptoms  are  seldom  acute.  The  patho- 
logical anatomy  is  said  to  be  usually  that  of  a  chronic  basic  meningitis. 

(7)  From  Nephritis. — In  addition  to  the  other  diseases  which  may 
simulate  tubercular  meningitis  should  be  mentioned  nephritis,  in  which 
the  symptoms  of  uraemia  simulate,  to  a  certain  extent,  those  of  tubercular 
meningitis.     The  urine  should  ahvavs  be  examined  in  doubtful  cases  of 


SPECIFIC   INFECTIOUS   DISEASES.  409 

this  kind.  Wlien  urpemic  symptoms  resulting  from  nephritis  are  present 
the  disease  will  be  shown  by  such  examination,  and  we  are  thus  able  to 
diflerentiate  it  from  tubercular  meningitis. 

(8)  From  Epidemic  Cerebrospinal  Meningitis. — It  is  often  quite  difficult 
to  differentiate  the  early  stages  of  tubercular  meningitis  from  those  of 
cerebro-spinal  meningitis.  In  typical  cases,  however,  the  diagnosis  is  not 
difficult,  as  the  long  prodromal  period  of  tubercular  meningitis,  as  a  rule, 
does  not  occur  in  cerebro-spinal  meningitis.  The  temperature  in  the  latter 
disease  is  high  in  comparison  ^^^th  the  former,  in  which  it  is  moderate.  In 
fact,  all  the  symptoms  of  cerebro-spinal  meningitLs  are  markedly  acute  in 
comparison  ^vith  those  of  tubercular  meningitis,  which  is  essentially  a  dis- 
ease of  a  subacute  character.  The  sudden  onset,  extreme  hyperjesthesia 
and  sensitiveness  to  sound,  intense  headache,  and  marked  tenderness  on 
pressure  over  the  spine,  so  common  in  cerebro-spinal  meningitis,  are 
seldom  met  wdth  in  the  tubercular  form.  The  absence  of  leucocytosis 
points  strongly  to  tubercular  menmgitis  ;  if  leucoc}iosis  is  present,  it  is 
of  little  value  in  the  diiferential  diagnosis.  The  presence  of  iodophilia  and 
leucocytosis  points  strongly  to  cerebro-spinal  or  acute  septic  meningitis  as 
against  a  tubercular  meningitis. 

(9)  From  Acute  Meningitis. — The  symptoms  of  meningitis  in  general 
can,  in  the  great  majority  of  cases,  be  differentiated  from  other  diseases, 
provided  that  w^e  do  not  attempt  to  make  the  diagnosis  too  early. 

Having  determined  that  the  disease  is  of  cerebral  origin,  we  must  next 
differentiate  betw^een  the  tubercular  and  the  other  forms  of  meningitis  by 
means  of  the  broad  rules  of  which  we  have  just  spoken,  and  which,  we 
have  condensed  and  simplified  by  means  of  the  following  table  : 

TABLE  56. 

Cerebral    Mexixgitis. 

Ac2ite  Forrn.  Tubercular  Form. 

Usually  secondary  (possibly  primary).  Secondary. 

Not  hereditary.  Hereditary. 

Acute.  Subacute. 

Prodromata  short,  if  any.  Prodromata  long,  decided. 

Headache  severe  at  once,  with  delirium  early,  Headache  less  severe  at  first,  but  gradually 

and  soon  followed  by  somnolence.  increasing  ;    delirium    less    common    and 

milder. 

Photophobia  estreme.  Photophobia  not  so  marked. 

Convulsions  violent.  Convulsions  less  violent. 

Temperature  high.  Temperature  moderate. 

Pulse  and  respiration  rapid.  Pulse  and  respiration  slow  and  irregular. 

Duration  short.  Duration  long. 

Cerebro-spinal  fluid  turbid,  with  preponder-  Cerebro-spinal    fluid   less   turbid,    with    pre- 

ance  of  polymorphonuclear  cells.  ponderance  of  lymphoid  cells. 

Leucocytosis  present.  Leucocytosis  sometimes  present,  often  absent. 

Iodophilia  present.  Iodophilia  absent. 

Presence  of  specific  organism  in  the  cerebro-  Presence  of  tubercle  bacillus  in  cerebro-spinal 

spinal  fluid.  fluid. 

Transudation  into  the  ventricles  may  occur  in  either  form.  The  younger  the  infant  the 
nearer  the  two  forms  approach  each  other  in  the  similarity  of  their  symptoms. 


410  PEDIATFlICS. 

Prognosis. — When  we  are  sure  of  our  diagnosis,  we  believe  that  in  our 
prognosis  we  should  give  no  hope  of  recovery  whatever,  except  that  in 
extremely  rare  cases  a  temporary  remission  may  take  place.  The  reported 
cases  of  absolute  recovery  from  tubercular  meningitis  cannot  but  be  looked 
upon  with  scepticism.  Indeed,  the  acute  forms  of  meningitis  simulate  the 
tubercular  so  closely  that  \\dthout  post-mortem  verification  recoveries  can 
be  supposed  to  be  possible,  but  can  hardly  be  accepted  as  proved. 

Treatment. — The  treatment  of  tubercular  meningitis  up  to  the  time 
when  the  diagnosis  is  established  should  be  purely  symptomatic  ;  later  we 
should  make  the  child  comfortable  by  every  means  in  our  power.  As  no 
case  of  tubercular  meningitis  has  ever  been  proved  to  be  cured  by  iodide 
of  potassium  or  any  other  drug,  it  is  useless  and  unwise  to  encourage 
ourselves  and  the  parents  by  false  hopes  of  good  results  arising  from  the 
administration  of  any  drug  whatever.  Up  to  the  present  time  our  knowl- 
edge of  the  disease  justifies  us  only  in  using  drugs  as  palliatives  for  the 
child's  suffering. 

The  following  cases  illustrate  the  different  phases  of  tubercular  menin- 
gitis. The  first  case  illustrates  a  type  of  disease  such  as  may  occur  in 
the  first  year  of  life  : 

A  male  infant,  ten  months  old,  had  always  been  well  and  strong.  For  a  few  days 
before  he  was  seen  he  had  been  rather  dull  and  feverish,  but  had  shown  no  other  ab- 
normal symptoms.  He  was  evidently  cutting  some  teeth  at  that  time.  On  the  day  we 
saw  him,  except  that  he  was  somewhat  fretful  and  put  his  hands  to  his  mouth  as 
though  his  gums  were  disturbing  him,  he  seemed  very  well,  and  careful  physical  exam- 
ination revealed  nothing  abnormal  in  the  ear,  throat,  chest,  or  abdomen.  On  the  day 
following  our  visit  the  slight  symptoms  of  indisposition  which  he  had  previously  shown 
disappeared,  and  he  played  with  a  toy  whistle,  blowing  it  himself,  and  seemed  to  be 
very  well.  This  condition  lasted  for  two  or  three  days,  when  he  became  stupid  and  un- 
conscious, and  about  the  tenth  day  from  the  time  he  first  came  under  our  observation 
he  died  in  convulsions. 

This  case  should  impress  upon  us  the  difficulty  of  making  a  diagnosis  in  the  early 
period  of  a  tubercular  meningitis,  and  how  guarded  we  should  be  in  giving  a  prognosis 
in  young  infants,  even  when  the  character  of  the  disturbance  is  very  slight. 

The  next  case  illustrates  a  tubercular  meningitis  occurring  in  a  child 
two  and  a  half  years  of  age : 

The  history  of  the  case  showed  that  the  father's  mother  and  the  mother's  mother 
and  brother  had  died  of  consumption.  When  the  patient  was  one  year  old  he  had 
measles  ;  otherwise  he  had  always  been  well.  About  two  or  three  weeks  before  he  was 
first  seen  it  was  noticed  that  the  child  slept  more  than  usual.  At  that  time  he  appeared 
to  be  feverish,  his  tongue  was  coated,  but  there  was  no  nausea  nor  vomiting.  A  few 
days  later  he  vomited  once  or  twice  during  the  day.  The  bowels  were  constipated. 
Eight  days  before  entering  the  hospital  he  had  a  slight  convulsion,  and  three  days  later 
he  cried  a  great  deal,  as  if  in  pain.  Two  days  before  entering  the  hospital  he  had  a 
number  of  convulsions  during  the  night,  each  lasting  about  ten  minutes.  On  the  fol- 
lowing day  the  convulsions  recurred.  On  the  day  he  entered  the  hospital  he  began  to 
have  convulsions  at  three  o'clock,  which  lasted  about  two  and  a  half  hours.     At  that  time 


SPECIFIC    INFECTIOUS   DISEASES. 


411 


he  was  noticed  to  have  marked  internal  strabismus  of  the  left  eye  and  slight  strabismus 
of  the  right  eye.  The  muscles  of  the  neck  were  somewhat  contracted.  There  was  no 
paralysis  of  the  extremities. 

The  pupils  were  equal,  reacted  to  light,  and  were  somewhat  dilated.  The  con- 
junctivae were  injected,  the  left  one  especially  so.  Sensation  was  not  impaired.  The 
knee-jerks  and  ankle-clonus  were  absent.  There  Avas  a  marked  tache  cerebrale.  The 
respirations  were  irregular  and  sometimes  of  the  Cheyne-Stokes  type.  The  child  was 
unconscious  and  very  pale.  The  heart's  action  was  very  rapid,  sometimes  as  high  as  200 
beats  in  a  minute.  No  souffles  were  detected.  The  temperature  was  38.3°  C.  (101° 
F.).  During  the  next  day  the  child  lay  in  a  state  of  stupor.  He  continually  moved  the 
left  forefinger  and  thumb,  kept  drawing  the  head  to  the  left,  and  was  very  restless.  He 
was  reported  to  have  cried  all  night  and  to  have  put  his  hand  to  his  left  ear.  He  lay 
with  his  eyes  wide  open,  took  nourishment  well,  and  had  less  strabismus  than  when  he 
entered  the  hospital.  On  the  following  day  (about  the  thirteenth  day  of  the  disease)  he 
became  very  restless,  had  sordes  on  the  teeth,  and  his  tongue  was  very  dry.  Examina- 
tion of  the  ears  showed  nothing  abnormal.  The  abdomen  was  somewhat  retracted. 
The  bowels  were  moved  regularly,  and  the  movements  appeared  to  be  well  digested. 
He  took  about  90  c.c.  (8  ounces)  of  milk  every  two  hours.  On  the  following  day  there 
was  no  especial  change,  except  that  the  muscles  of  the  neck  were  firmly  contracted  and 
the  tache  cerebrale  came  out  more  slowly  than  on  the  previous  day.  A  slight  paralysis 
of  the  left  side  of  the  face  appeared  on  this  day.  The  left  eyelid  moved  rather  slowly, 
and  the  left  corner  of  the  mouth  seemed  to  drop  a  little.  The  pulse  was  irregular,  of 
fair  strength,  and  intermittent.     He  did  not  take  his  nourishment  so  well. 

The  comatose  condition  and  other  signs  continued  without  improvement.  The  face 
became*  cyanotic,  the  respirations  Cheyne-Stokes  in  character,  the  pulse  irregular  and 
intermittent.     The  temperature  gradually  fell  until  it  was  37.2°  C.   (99°  F.)  in  the 

CHAKT   8. 


Days  of  Disease 

F. 

10 

11 

12 

13 

14 

15 

16 

17 

c 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99= 

TEMP. 
93° 

97° 

96° 
95° 

JilE 

ME 

ME 

ME 

ME 

ME 

ME 

ME 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

33.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5' 

35.0° 

/ 

/ 

/ 

1 

/ 

b 

{/ 

'\ 

,      / 

/ 

1/1 

^ 

~ 

Tubercular  meningitis.    Male,  23^  years  old. 


morning  of  the  sixteenth  day  of  the  disease,  when  it  began  to  rise  rapidly  until  it 
reached  41.1°  C.  (106°  F.)  in  the  evening  of  the  seventeenth  day,  when  the  child  died. 

The  autopsy  showed  the  following  lesions  : 

Heart. — The  right  ventricle  was  dilated  and  the  valves  Avere  normal. 


412  PEDIATRICS. 

Linii/i.—\  imnil)i;r  of  small,  flattened,  yray  masses  were  fninid  in  tin-  jileiiia  ;  (in 
section  tiiey  were  fonncl  to  I)e  miliary  lujjercles.  Tin;  right  lung  was  adherent  to  the 
parietal  iileura  by  strong  fibrinons  adhesions,  beneath  which  were  miliary  tubercles, 
especially  in  the  areas  covering  the  ribs,  the  diaphragm,  and  the  upper  third  nf  the 
sternum.  A  small  number  were  also  found  in  the  substance  of  tlio  lung.  The  bron- 
chial glands  were  enlarged,  (me  of  them  being  1.2  cm.  (.]  inch)  in  diameter.  This 
gland  on  section  was  yellow  and  somewhat  broken  down. 

Spleen. — The  spleen  was  of  about  normal  size  and  showed  many  flattened  miliary 
tubercles.  Beneath  the  capsule,  on  section,  there  were  found  numerous  tubercles  of 
varying  size  :  the  larger  ones  Avere  yellow  and  the  smaller  ones  gray. 

Peritoneum. — There  were  found  scattered  all  through  the  omentum,  on  the  surface 
of  the  root  of  the  mesentery,  over  the  bladder,  and  particularly  on  the  under  sur- 
face of  the  right  side  of  the  diaphragm,  numerous  miliary  tubercles.  The  lymph- 
glands  of  the  mesentery  were  considerably  enlarged,  particularly  beneath  the  stomach. 
On  section  they  showed  tubercles,  most  of  which  were  quite  large  and  had  yellow, 
cheesy  centres. 

Intestine. — In  the  intestine  about  the  ileo-ctecal  valve  there  were  several  small 
ulcerations  apparently  in  the  process  of  repair.  In  the  caecum  there  were  two  narrow 
ulcers  about  1.5  cm.  (|  inch)  long.  The  bases  were  injected.  The  walls  were  not 
broken  down. 

Liver. — Many  rather  large  tubercles  were  found  beneath  the  capsule  of  the  liver. 
They  were  flat,  but  not  cheesy. 

Brain. — The  convolutions  of  the  brain  werejattened.  There  was  marked  fibrino- 
serous  exudation  at  the  base  of  the  brain,  covering  the  optic  commissures  and  the  ad- 
joining parts.  The  third  nerve  was  chiefly  injected.  Many  small  tubercles  were 
present  in  the  fissures  of  Sylvius  and  over  the  convexities  of  the  brain.  In  the  right 
half  of  the  cerebellum,  just  beneath  the  pia,  about  the  centre  of  the  base,  was  a  yellow 
nodule  about  6  mm.  (l  inch)  in  diameter.  In  the  left  lateral  ventricle  anterior  to  the 
velum  interpositum  was  a  similar  nodule  about  3  mm.  {^  inch)  in  diameter  projecting 
into  the  ventricles.  Both  ventricles  were  moderately  dilated  by  the  serous  fluid.  The 
ependyma  was  everywhere  granular  :  this  condition  was  due  to  small,  gray,  transparent 
tubercles.     No  tubercles  were  found  in  the  third  or  fourth  ventricles. 

Kidneys. — The  kidneys  contained  a  few  rather  large  grayish  areas  with  here  and 
there  a  yellowish  speck. 

The  pathological  diagnosis  of  the  case  was — 

Old  tubercular  ulcers  of  the  intestine  :  chronic  tuberculosis  of  the  mesenteric  and 
bronchial  lymph-glands  ;  solitary  tubercle  of  the  brain  ;  miliary  tuberculosis  of  the  pia, 
lateral  ventricles,  pleura,  lung,  spleen,  kidney,  peritoneum,  and  liver. 

Another  case  was  that  of  a  boy  three  years  old. 

There  was  no  history  of  tubercular  or  syphilitic  disease  in  the  parents.  Three 
weeks  before  entering  the  hospital,  the  child,  who  had  previously  been  healthy,  began 
to  complain  of  pain  in  the  abdomen,  anorexia,  and  general  malaise.  Somewhat  later 
it  was  noticed  that  the  eyes  would  at  times  turn  inwards  and  that  the  head  ivould  be 
drawn  back.  He  was  in  this  condition  for  two  weeks  before  entering  the  hospital.  On 
March  13  he  was  brought  to  the  hospital,  and  was  found  to  have  a  temperature  of  38.4° 
C.  (101. 2°F.),  a  pulse  of  120,  not  intermitting,  and  respirations  40.  He  was  in  a  stupid 
and  droAvsy  condition.  His  head  was  drawn  back,  and  he  would  not  lie  on  his  back. 
The  tongue  was  not  coated.  An  examination  of  the  heart,  lungs,  and  urine  showed 
nothing  abnormal.  An  examination  of  the  eyes  showed  the  pupils  to  be  dilated,  but 
equal  in  size  and  reacting  to  light.  There  were  internal  strabismus  of  both  eyes,  an 
optic  neuritis,  and  the  beginning  of  an  atrophy  following  the  neuritis.  The  patellar 
reflexes  Avere  absent,   and  there  was  no  ankle-clonus.     The  superficial  reflexes  were 


SPECIFIC    INFECTIOUS   DISEASES. 


413 


normal.  There  was  no  tenderness  of  the  head  or  spine.  Au  examination  of  the  ear 
showed  nothing  abnormal.  On  March  16  he  showed  nystagmus  with  conjugate  devia- 
tion to  the  right  or  to  the  left,  according  to  the  side  on  which  he  lay.  No  tache  c'erebrale 
Avas  present.  On  the  17th  an  erythematous  congestion  was  noticed  on  the  right  cheek, 
and  he  became  still  more  somnolent.  On  the  18th  the  head  was  much  less  retracted. 
He  had  vomited  once  during  the  night  and  once  in  the  morning.  On  the  21st  he  had 
a  convulsion,  which  was  the  first  that  had  occurred  during  the  course  of  the  illness. 
He  was  also  found  to  have  partial  opisthotonos.  The  legs  did  not  participate  in  the 
contraction,  but  the  head  was  drawn  back  almost  to  the  buttocks.  His  respirations 
became  Cheyne-Stokes  in  character.  On  the  same  day  he  had  four  or  five  convulsions, 
and  remained  in  a  condition  of  opisthotonos  in  the  intervals  between  them.  These 
convulsive  attacks  lasted  about  half  a  minute  each,   and  the  intervals  between  them 


Fi...  104. 


Tubercular  meningritis.    Male,  S  vears  old. 


were  about  four  minutes.  There  was  incontinence  of  urine  and  of  fseces.  The  pulse 
was  rapid  and  irregular,  and  the  extremities  were  cold.  The  tache  cerebrale  was  ob- 
tained for  the  first  time,  and  lasted  for  twelve  minutes.  0.12  gramme  (2  grains) 
of  chloral  and  2  grammes  (i  drachm)  of  brandy  were  given  subcutaneously.  The 
convulsions  ceased,  the  opisthotonos  disappeared  in  twenty  minutes,  and  the  child  re- 
mained quiet. 

On  the  26th  the  record  was  that  for  two  days  the  child  had  been  decidedly  better, 
the  retraction  and  strabismus  were  less,  the  nystagmus  had  disappeared,  and  he  had 
recognized  and  spoken  to  his  father.  The  tache  cerebrale  could  be  obtained,  but  was 
less  distinct,  and  the  temperature  was  normal.  On  the  28th  he  became  worse  again. 
His  head  was  again  reiracted,  but  he  was  not  wholly  unconscious.  There  was  reten- 
tion of  urine,  for  whicli  he  had  to  be  catheterized.  On  the  29th  he  had  a  convulsion 
lasting  three  minutes,  in  which  the  right  arm  was  jerked  up  over  his  head.  This  was 
followed  by  partial  opisthotonos,  and  then  by  a  general  convulsion  lasting  two  or  three 
minutes,  during  which  his  eyes  rolled  up.  At  times  he  would  have  convulsive  move- 
ments and  tremor  without  actual  convulsions.  This  condition  continued  for  nine  days. 
He  remained  unconscious,  with  his  eyes  open  and  staring,  the  head  drawn  back,  the 
abdomen  retracted,  and  the  tache  cerebrale  A'ery  marked.  The  respirations  were  of  a 
pronounced   Cheyne-Stokes  type,  and  the  pulse  intermittent.     The  temperature  varied 


414  PEDIATRICS. 

from  37.2°  to  38.8°  C,  (99°  to  102°  F.),  but  rose  witliin  the  last  twelve  hours  to  40° 
C.  (104°  F.),  indicating  that  the  fatal  issue  of  the  case  was  very  near. 

On  the  following  day  there  were  a  number  of  convulsions  occurring  in  rapid  suc- 
cession, especially  involving  the  left  side.  These  convulsions  continued  for  five  hours 
before  the  child  died. 

The  following  case  (Fig.  105)  simulated  cerebro-spinal  meningitis  very 
closely,  and  illustrates  an  important  fact,  that  a  child  may  recover  tem- 
porarily from  an  attack  of  tubercular  meningitis  and  then  die  of  a  recur- 
rent attack. 

A  child,  twenty-one  months  old,  was  stated  to  have  been  healthy  until  it  was  nine 
months  old.  At  that  time  it  had  a  convulsion,  which  first  affected  the  right  and  then 
the  left  side.  It  was  unconscious  for  ten  days,  and  was  somnolent  for  four  weeks. 
Two  or  three  weeks  later  its  general  condition  improved.  During  this  time  it  did  not 
use  the  muscles  of  its  left  side  or  limbs,  and  it  could  laugh  only  with  the  right  side  of  its 
face.  Its  body  was  turned  continuously  to  the  left  ;  sensation  was  not  interfered  with. 
It  gained  slowly  in  strength,  and  the  symptoms  gradually  disappeared,  until  it  was  thir- 
teen months  old,  when  it  seemed  to  be  comparatively  well,  all  motor  disturbances  having 
ceased.  In  the  following  months  it  had  a  few  slight  attacks  of  the  same  nature.  The 
final  attack  from  which  it  died  occurred  when  it  was  twenty  months  old,  and  began 
with  a  convulsion  on  the  right  side  with  twitching  of  the  muscles  on  the  left  side  and 
frothing  at  the  mouth.  There  was  also  ptosis  of  the  left  eye.  It  did  not  cry  out  when 
going  into  the  convulsions,  but  had  marked  opisthotonos,  which  lasted,  to  a  greater  or 
less  extent,  for  five  weeks.  During  these  five  weeks  it  was  unconscious,  and  there  were 
several  slighter  attacks. 

On  entering  the  hospital,  physical  examination  showed  that  the  child  was  of  me- 
dium size,  pale,  poorly  developed  and  nourished,  and  unable  to  stand,  the  left  leg  being 
weaker  than  the  right.  Nothing  abnormal  was  found  in  connection  with  the  heart  or 
lungs.  She  could  use  her  extremities  partially,  but  there  was  an  evident  motor  disturb- 
ance of  the  whole  of  the  left  side,  and  she  took  hold  of  objects  with  her  right  hand 
only.  The  index  and  little  finger  of  the  left  hand  were  frequently  found  to  be 
extended,  the  second  and  third  fingers  being  flexed  partially.  There  was  also  slight 
drooping  of  the  left  eyelid,  and  the  lines  of  the  left  side  of  the  face  were  obliterated.  There 
was  a  very  slight  drooping  of  the  left  corner  of  the  mouth.  There  was  slight  strabis- 
mus of  the  left  eye,  and  an  apparent  lack  of  power  of  the  left  external  rectus  muscle. 
The  patellar  reflexes  were  exaggerated  on  the  left  side.  Examination  showed  the  ankle- 
clonus  to  be  absent.  The  epiphyses  of  the  wrists  were  somewhat  enlarged.  The 
child  could  not  speak,  and  apparently  could  not  understand  readily.  No  evidence  of  a 
history  of  cerebral  injury  could  be  obtained.  The  circumference  of  the  chest  was  1  cm. 
(f  inch)  larger  than  that  of  the  head.  The  cause  of  the  disease  was  so  obscure  that  at 
this  period  the  diagnosis  could  not  be  definitely  made,  the  supposition  being  that  the 
child  was  suffering  from  the  results  of  an  attack  of  cerebro-spinal  meningitis,  or  possi- 
bly from  tertiary  syphilis,  or  that  a  cerebral  hemorrhage  had  taken  place,  with  a  result- 
ing spastic  paralysis. 

While  in  the  hospital  the  child  presented  a  number  of  different  nervous  phenomena. 
At  times  she  would  appear  to  be  for  days  semi-comatose  and  would  not  take  notice  of 
anything  about  her  ;  the  eyes  rolled  up  and  she  would  have  slight  twitching  of  the 
body,  but  this  was  not  localized,  and  there  were  no  convulsions.  At  another  time, 
while  sleeping  quietly  during  the  night,  she  was  found  to  be  unconscious  in  the  morn- 
ing, and  to  have  her  head  slightly  drawn  back  and  her  eyes  turned  up.  Nystagmus 
was  present,  and  the  pupils  were  dilated  and  did  not  react  to  light,  but  were  equal  in 
size.      Clonic   twitching  of  the  right  foot  and  the  muscles  of  the  right  side,   flexion 


SPECIFIC    INFECTIOUS   DISEASES. 


415 


of  the  fingers  of  the  right  hand  over  the  thumb,  and  twitching  of  the  muscles  of  the 
wrist  sometimes  occurred.  There  was  twitcliing  of  tlie  fibres  of  the  sterno- mastoid 
muscle  on  the  right  side.  There  was  also  twitching  of  the  right  side  of  the  face. 
There  was  no  spasm  on  the  left  side,  except  of  the  left  sterno-mastoid,  but  there  was  a 


105. 


Kecurrent  tubercular  meningitis.    Female,  21  months  old. 

nystagmus  of  the  eye.  These  clonic  twitchings  were  rhythmical  and.  occurred  180 
times  a  minute.  The  pulse  was  172,  and  was  very  feeble.  The  respirations  were  80, 
rapid  and  rattling  ;  the  temperature  was  39.4°  C.  (103°  F.) 

From  2  a.  m.  until  5  a.  m.  0.36  gramme  (6  grains)  of  chloral  was  given  by  enema, 
and  0.36  gramme  (6  grains)  of  bromide  of  potassium  was  given  every  three-quarters  of 
an  hour  by  the  mouth,  alternating  with  the  chloral.  The  spasms  became  less  marked 
after  3  a.m.,  but  continued  in  a  mild  degree  up  to  11  a.m.  During  the  remainder  of 
the  day  and  the  next  two  days  the  child  lay  in  a  stupor,  but  had  no  convulsions.  It 
was  able  to  swallow  brandy  and  milk,  which  were  given  to  it  by  the  mouth  in  small 
quantities  at  different  intervals. 

On  the  next  day  she  apparently  had  attacks  of  pain,  when  she  would  straighten 
herself  out,  throw  back  her  head,  and  cry  out.  On  the  following  day,  she  began  to 
have  the  same  twitchings  as  in  the  attack  previously  mentioned.  They  were  of  the 
same  character,  except  that  the  extensor  muscles  of  the  left  foot  contracted  feebly. 

On  the  following  day  it  was  reported  that  she  had  had  no  convulsions,  but  appa- 
rent attacks  of  pain,  when  she  would  cry  out  and  throw  her  head  back,  and  that  she 
had  had  another  attack  of  opisthotonos,  which  was  so  much  more  marked  than  before 
that  the  heels  almost  touched  the  back  of  her  head.  The  next  symptom  which 
appeared  was  stupor.     The  temperature  at  this  time  was  considerably  elevated. 

On  the  following  day  there  were  no  convulsions,  and  her  condition  was  about  the 
same  as  on  the  previous  day,  but  the  head  was  drawn  back  and  was  rigid,  and  the 
legs  were  drawn  up  and  were  held  rigidly.  She  lay  in  this  condition,  most  of  the  time 
in  a  stupor,  crying  out  occasionally,  and  moving  her  left  hand  and  arm  more  than  she 
did  the  right.  At  times  she  would  appear  to  be  sleeping  naturally  and  the  rigidity 
would  pass  away 

The  opisthotonos  gradually  become  more  marked  and  more  frequent  in  its  occur- 
rence, and,  although  the  bowels  were  moved  regularly  every  day,  she  took  less  nourish- 
ment, and  the  temperature  continued  to  rise,  and  varied  from  37.7°  to  40°  C.  (100°  to 
104°  F.). 

During  the  last  week  of  her  life  the  opisthotonos  became  less  marked,  and  at 
times  passed  away  entirely.  She  opened  her  eyes,  but  the  pupils  reacted  very  slightly. 
The  left  pupil  became  somewhat  larger  than  the  right  and  reacted  slightly,  while  the 


416 


PEDIATHICS. 


right  pupil  did  not  react  at  all.  The  spastic  conditit)ii  of  the  righl  wiist  and  left  knee 
persisted,  the  patellar  reflexes  were  equal  and  normal,  and  the  child  lay  in  a  semi- 
stupor,  with  a  temperature  varying  from  38.3°  to  39.4°  C.  (101°  to  103°  F.).  She 
took  less  and  less  nourishment,  and  had  a  slight  cough.  She  gradually  lost  in  weight 
and  strength,  and  on  the  day  before  she  died  her  respirations  for  a  time  were  very 
rapid,  running  up  to  100  a  minute.     Death  took  place  apparently  from  exhaustion. 

The  long  duration  of  this  last  attack,  embracing  a  period  of  eight  or  nine  weeks, 
made  the  diagnosis  very  difficult. 

The  autopsy  showed  the  following  pathological  conditions  :  sunacute  tubercular 
meningitis,  chronic  granular  ependymitis,  chronic  hydrocephalus,  atrophy  of  the  brain- 
substance,  miliary  tuberculosis  of  the  lungs,  spleen,  and  kidneys,  and  chronic  tubercu- 
losis of  the  lung. 

Some  of  the  tubercular  lesions  were  of  recent  growth,  while  others  were  evidently 
old  ones  and  representative  of  a  former  attack.  The  presence  of  older  tubercular 
lesions  in  the  meninges,  as  well  as  of  those  which  produced  the  symptoms  in  the  last 
attack  from  which  the  infant  died,  proved  that  the  case  was  one  of  recurrent  tuber- 
cular meningitis. 

It  is  not  unusual  to  meet  with  a  tubercular  meningitis  secondary  to 
tubercular  disease  of  the  spine.  Tubercular  meningitis  may  also  occur  in 
connection  with  disease  of  the  hip,  the  latter  being  much  more  common 
than  when  the  spine  is  affected. 

The  tubercular  form  of  otitis  is  not  uncommon,  and  it  may  be  the 
starting-point  for  tubercular  meningitis.  Surgeons  should,  therefore, 
watch  carefully  the  possible  complication  of  tubercular  meningitis  when 
treating  tubercular  disease  of  the  bones  and  joints  and  of  the  ear. 

The  fohowing  case  was  one  of  tubercular  meningitis,  associated  with 
an  acute  miliary  tuberculosis,  occurring  in  my  wards  at  the  Children's 
Hospital.  The  pathological  appearances  on  the  base  of  the  brain,  as 
shown  on  atopsy,  are  represented  in  Plate  I,  frontispiece. 

The  child  entered  the  hospital  on  September  13.  She  was  three  years  of  age. 
With  the  exception  of  an  attack  of  whooping-cough  she  had  been  well  until  two  weeks 
before  entrance,  when  she  was  taken  with  vomiting  and  diarrhoea.  She  complained  of 
headache  and  pain  in  her  stomach,  and  there  had  been  continous  fever.  The  diarrhoea 
lasted  a  few  days,  and  she  then  became  constipated.  Four  days  before  entrance  the 
muscles  of  the  neck  became  stiff.     No  further  history  could  be  obtained. 

The  physical  examination  showed  the  child  to  be  well  developed  and  fairly  nour- 
ished, but  anaemic.  She  lay  in  a  stupor  most  of  the  time,  but  could  be  aroused.  The 
pupils  were  equal  and  reacted  sluggishly.  The  tongue  was  coated,  the  throat,  heart  and 
lungs  showed  nothing.  The  head  was  slightly  retracted,  and  the  posterior  muscles  of  _ 
the  neck  were  rigid.  The  abdomen  was  not  retracted,  and  nothing  abnormal  was  de- 
tected. A  tache  ctrebrale  was  present.  The  knee-jerks  were  normal.  Babinsky's 
sign  was  present  in  both  feet,  and  Kernig's  sign  was  also  obtained. 

On  September  14  there  were  some  convulsive  movements  of  the  right  extremities, 
and  breathing  was  somewhat  labored. 

On  September  15  the  child  took  her  food  very  poorly,  and  could  not  swallow  well. 
There  were  convulsive  movements,  but  no  general  convulsion. 

On  September  16  the  legs  were  rigid  and  held  in  extreme  extension  most  of  the 
time.     The  pupils  were  unequal  and  dilated,  and  did  not  react  to  light. 

On  September  17  strabismus  of  left  eye  developed,  but  was  not  constant.  There 
was  convulsive  twitching  of  the  limbs,  with  rigidity  most  of  the  time.  The  face  was 
flushed,  perspiration  was  very  free,  and  the  abdomen  was  somewhat  distended. 


SPECIFIC  INFECTIOUS  DISEASES. 


417 


On  September  18  the  condition  remained  the  same,  except  for  the  additional  symp- 
tom of  Cheyne-Stokes  respiration.  The  rectal  feedings  were  not  retained,  and  it  was 
impossible  to  insert  a  catheter  for  nasal  feedings,  owing  to  the  swollen  condition  of 
the  mucous  membrane  of  the  nares  and  the  difficult  breathing. 

On  Septembei-  21  the  respiration  had  become  more  sighing  in  character.  The 
child  perspired  very  freely.     The  white  blood  count  was  8000. 

On  September  22  the  condition,  which  had  remained  practically  the  same,  except 
for  the  rising  temperature  and  accelerated  pulse,  became  worse.  The  child  seemed  to 
grow  weak  rapidly,  and  the  respirations  and  pulse  became  irregular  and  the  child 
finally  died.     Chart  9,  page  417,  shows  the  course  of  the  temperature. 


CHART   9. 


CHART  10. 


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Tubercular  meningitis.    Age,  3  years. 


Tubercular  meningitis.    Age,  2  years. 


Lumbar  puncture  was  performed  immediately  after  death,  and  a  slightly  cloudy 
fluid  with  flecks  of  fibrin  was  obtained. 

The  autopsy  showed  the  original  focus  to  be  in  a  bronchial  lymph-gland,  which 
was  enlarged  and  caseous,  with  a  cavity  at  the  centre.  There  were  found  miliary  tuber- 
culosis of  the  lungs,  liver,  spleen,  and  kidneys,  tubercular  meningitis,  and  tubercular 
bronchial  glands.  The  brain  weighed  1080  grammes.  At  the  base,  around  the  pons, 
and  in  the  fissure  of  Sylvius  there  was  a  yellow,  gelatinous  material,  while  along  the 
blood-vessels  of  the  pia  were  scattered  numerous  miliary  tubercles,  sometimes  single 
and  again  confluent. 


The  following  was  a  case  of  tubercular  meningitis  with  symptoms  of 
comparatively  short  duration  and  associated  mth  a  general  miliary  tuber- 
culosis. It  is  especially  interesting  in  that  the  tubercular  process,  as  shown 
by  the  autopsy,  and  as  represented  in  Plate  I.,  frontispiece,  was  most 
highly  and  typically  developed  on  the  convexity  of  the  brain  instead  of  at 
the  base,  as  is  generally  the  rule. 

27 


418  PEDIATRICS. 

The  child  was  two  years  old.  She  had  been  losing  flesh  and  strength  for  about 
two  months.  Two  weeks  before  entering  my  hospital  wards  she  was  taken  with 
vomiting  without  special  reference  to  the  taking  of  food.  This  was  the  only  symptom 
the  parents  noticed  until  three  days  before  entrance,  when  convulsions  and  fever  de- 
veloped.    Nothing  more  defmitf  could  be  learned  from  the  parents. 

The  physical  examination  showed  a  child  who  was  fairly  developed  and  nourished, 
pale,  pupils  widely  dilated,  the  right  reacting  sluggishly,  and  the  left  not  at  all.  The 
eyes  were  rolled  up,  but  there  was  no  strabismus.  The  head  was  retracted,  there  was 
no  tenderness  along  the  spine.  The  tongue  was  slightly  coated.  There  was  a  slight 
rosary.  The  throat,  heart,  lungs,  and  abdomen  presented  nothing  abnormal  so  far  as 
could  be  determined.  There  were  no  petechias.  A  tache  cerebrale  was  present.  The 
knee-jerks  were  slightly  exaggerated  on  both  sides.  The  plantar  reflexes  were  normal. 
Babinsky's  sign  was  present  in  both  feet.  Kernig"s  sign  was  absent.  The  child  lay 
in  a  stupor.     The  white  blood  count  was  6000. 

On  the  following  day  there  were  convulsive  twitchings  of  the  right  arm  and  right 
side  of  the  face.  On  the  third  day  after  entrance  these  signs  became  more  marked, 
the  respirations  Cheyne-Stokes  in  character,  the  pulse  rapid,  irregular,  and  small. 
There  were  no  convulsions  of  the  entire  body,  but  the  right  arm  was  flexed  at  the 
elbow.  These  symptoms  continued  until  the  fourth  day,  when  the  child  died.  The 
course  of  the  temperature  is  shown  in  Chart  10,  page  417. 

Lumbar  puncture,  done  immediately  after  death,  gave  a  slightly  turbid  fluid,  and 
flecks  of  fibrin  separated  out.  No  tubercle  bacilli  were  discovered  in  the  sediment  from 
lumbar  puncture. 

At  the  autopsy  the  following  condition  of  the  brain  was  found  : 
.  The  dura  was  tense  and  bulging  :  the  superior  longitudinal  sinus  was  normal ; 
the  gyri  were  flattened  ;  the  sulci  were  partly  obliterated  :  the  vessels  of  the  pi- 
arachnoid  over  the  vertex  were  markedly  injected,  and  the  cerebro-spinal  fluid  consid- 
erably increased.  In  tbe  pia  mater  over  the  superior  surface  of  the  right  frontal  lobe, 
and  extending  to  the  mesial  surface,  was  an  area  5  by  3  cm.,  with  opaque,  grayish- 
yellow,  single  and  conglomerate  tubercles  ;  the  single  tubercles  averaging  one  mm.  in 
size.  Tubercles  were  present  in  great  numbers  in  the  sulci,  adjacent  to  the  blood-vessels, 
but  were  also  distributed  upon  the  gyri  over  both  hemispheres,  but  especially  over  the 
lateral  surfaces  of  the  parietal  lobes.  About  the  optic  chiasm  and  interpeduncular 
spaces  was  a  mass  of  semi-opaque  gelatinous  material  beneath  the  turbid  pia.  Around 
the  branches  of  the  middle  meningeal  artery,  and  especially  in  the  Sylvian  fissure,  was 
an  abundant  diffuse  flbrino-purulent  exudation.  Scattered  tubercles  were  found  over 
the  base,  but  in  less  numbers  than  over  the  vertex.  Many  were  scarcely  visible,  being 
nearly  transparent  and  less  than  a  millimetre  in  diameter. 

The  anatomical  diagnosis  was  :  tubercular  meningitis,  acute  miliary  tuberculosis 
of  the  lungs,  tubercular  ulceration  of  the  intestines,  tuberculosis  of  the  mesenteric 
lymph-nodes,  and  a  mild  degree  of  rhachitis. 

TUBERCULiOSIS  OF   THE  JOINTS. 

Tubercular  disease  of  the  joints  is  essentially  a  disease  of  childhood  ; 
it  is  very  rarely  congenital,  and  under  one  year  is  not  common.  In  1344 
cases  of  hip  disease,  1000  occurred  under  fifteen  years  of  age.  (Bradford 
and  Lovett.)  In  hip  disease,  for  example,  a  series  of  cases  from  the  Xew- 
York  Dispensary  showed  that  115  occurred  under  three,  316  from  three 
to  five,  509  from  five  to  ten,  140  from  ten  to  fifteen,  and  98  over  fifteen 
years.  This  may  be  taken  as  fairly  representative  of  the  general  liability 
to  the  diseases  at  different  ages. 


SPECIFIC   INFECTIOUS   DISEASES.  419 

At  the  Children's  Hospital,  Boston,  from  1869  to  1893,  3820  cases  of 
tuberculosis  of  the  joints  were  as  follows : 

TABLE   57. 

Spine : 1964 

Hip 1402 

Ankle " 300 

Knee 104 

Wrist 20 

Shoulder 15 

Elbow 15 

These  figures  are  similar  to  those  reported  by  other  American 
authors. 

With  regard  to  the  causation  of  tubercular  disease  of  the  joint,  it  may 
be  stated  that  the  element  of  heredity  is  to  be  found  in  a  large  proportion 
of  cases,  which  is  variously  estimated,  the  percentage,  according  to  differ- 
ent authors,  varying  from  twenty-four  (Croft)  to  sixty-eight  (Gibney) ;  an 
average  estimate  w^ould  perhaps  be  forty  per  cent.  (Nichols.) 

Traumatism  is  accepted  as  being  the  cause  of  chronic  disease  of  the 
joints  in  certain  cases  (Konig) ;  this  occurence,  also,  is  variously  estimated 
from  thirty-five  to  fifty  per  cent.  Chronic  tubercular  disease  of  the  joints 
follows  in  certain  cases  after  the  exanthemata,  especially  measles  and 
scarlet  fever. 

Pathological  Anatomy. — Tuberculosis  of  the  joints  in  children,  as  well 
as  in  adults,  is  now  much  more  uniformly  regarded  as  being  of  bony  origin 
than  was  formerly  supposed. 

The  existence  of  a  primary  synovial  tuberculosis  in  children  must  be 
regarded  as  extremely  rare,  and  only  to  be  demonstrated  by  the  examina- 
tion of  all  parts  of  the  bones  entering  into  the  formation  of  the  joint. 
Finding  a  tuberculosis  of  the  synovial  membrane  at  operation,  with  an  ob- 
vious bony  lesion,  cannot  be  accepted  as  proof  of  primary  synovial  disease. 

The  original  statement  of  Volkmann  is,  "The  fungous  inflammation  of 
the  joints  in  children  and  adults  begins  generally  not  at  all  as  an  arthrop- 
athy, but  as  a  pure  osteopathy,  with  a  very  circumscribed  condition  of 
tubercular  osteitis." 

Nichols,  in  the  examination  of  one  hundred  and  twenty  tubercular 
joints  from  children  and  adults,  did  not  find  one  joint  where,  if  all  the 
bones  entering  into  the  joints  were  sawed  open  in  thin  layers,  one  or 
more  old  bone  foci  were  not  found. 

The  process  by  which  joints  become  affected  by  tubercular  disease  is 
as  follows  :  A  tubercular  focus  develops  in  the  spongy  tissue  of  the  bone 
near  the  epiphysis,  and  by  an  extension  of  this  process  the  bone  is  de- 
stroyed in  the  line  of  least  resistance,  which  is  usually  towards  the  sur- 
face of  the  joint.  When  perforation  of  the  joint  by  this  focus  occurs,  the 
tubercle  bacilli  obtain  access  to  the  joint  cavity  and  a  tubercular  syno- 
vitis begins.  From  this  point  destruction  in  any  direction  is,  of  course, 
possible.     Under  favorable  conditions  of  rest  and  separation  of  the  surfaces 


420  PEDIATRICS. 

ot'  tlie  joint  by  traction,  in  certain  cases,  nature  tends  to  limit  the  process 
by  repairing  and  replacing  the  tubercular  tissue  by  the  formation  of  fibrous 
tissue  which  grows  into  and  replaces  the  tubercular  material  Tlie  soft 
parts  around  the  joint  are,  of  course,  secondarily  affected,  and  alDscesses 
are  a  frequent  complication. 

The  contents  of  a  tubercular  abscess  may  be  sterile  so  far  as  pyogenic 
organisms  are  concerned,  or  they  may  contain,  especially  in  their  later 
stages,  pyogenic  oKranisms.  Tubercle  bacilli  are  to  be  found  in  these 
abscesses  in  only  about  one-third  of  the  cases,  and,  as  a  rule,  only  after 
prolonged  search.  Inoculation  experiments  must  be  relied  upon  in  the 
majority  of  cases  to  establish  their  presence.  The  presence  of  leucocy- 
tosis  in  a  child  with  disease  of  a  jomt  does  not  establish  the  presence  of 
pyogenic  organisms 

Symptoms. — Hip. — Clironic  tubercular  disease  of  the  hip-joint,  com- 
monly known  as  hip  disease,  most  often  begins  \Yiih  lameness,  paroxysmal 
cries  at  night,  and  a  stiffness  in  the  joint  which  is  more  noticealDle  in  the 
morning  than  at  night.  The  pain  is  more  often  referred  to  the  knee  than 
to  the  hip.  and  may  be  very  severe  or  may  be  slight. 

On  examination  in  the  early  stages,  the  joint  is  found  to  be  somewhat 
limited  in  its  motions,  the  trochanter  is  slightly  thicker  than  the  one  in 
the  well  limb,  and  wasting  of  the  muscles  occurs  in  the  thigh  and  the  calf. 

The  prognosis  in  early  cases  is  excellent  for  the  restoration  of  a  useful 
limb,  and  even  in  the  late  cases  the  adoption  of  treatment  by  traction  gen- 
erally brings  alDout  good  results.  It  must,  however,  be  remembered  that 
these  childjen  are  tubercular,  and  that  a  certain  number  of  them  develop 
tubercular  meningitis  in  the  course  of  the  disease. 

Spine. — Chronic  tubercular  disease  of  the  spme,  or  Pott's  disease, 
begins  usually  mth  stiffness  of  the  back  and  pain  on  exertion,  which  is 
in  most  cases  referred  to  the  peripheral  end  of  the  nerves,  so  that  the 
pain  may  be  complained  of  either  in  the  abdomen  or  chest.  Such  cliil- 
dren  walk  mth  a  guarded  gait  and  stiffly,  and  when  tired  support  them- 
selves by  leaning  on  furniture  or  by  resting  the  hands  upon  the  tliighs. 

In  the  cervical  region  torticolhs  and  difficult  breathing  at  night  may 
be  the  only  symptoms.  In  the  lumbar  region  one  symptom  generally 
noticed  is  an  apparent  lordosis,  in  which  the  child  leans  far  backward,' 
Paralysis,  which  occurs  in  a  certain  proportion  of  cases  due  to  a  pressure 
from  meningitis  originating  at  the  seat  of  the  disease,  may  be  the  first  symp- 
tom :  it  is  accompanied  by  increased  reflexes  and  a  loss  of  power  in  the 
legs.  Psoas  a}3scess  is  a  common  complication  in  the  lower  part  of  the 
column,  and  the  first  spnptom  noticed  in  tliis  comphcation  is  generally 
inability  to  hyperextend  the  leg  upon  the  affected  side.  The  cliief  sign 
to  be  relied  upon  in  the  diagnosis  is  stiffness  in  some  part  of  the  spine. 
This  is  most  easily  detected  by  having  the  child  stoop  to  pick  up  objects 
from  the  floor,  and  by  laying  the  child  on  the  face  and  flexing  the  spine  by 
lifting  the  body  by  tlie  legs.     The  appearance  of  a  knuckle  occurs  early 


SPECIFIC    INFECTIOUS    DISEASES.  421 

ill  the  disease,  ])ut  it  is  most  important  tluit  the  diagnosis  slionld  ]je  made 
before  this  kiiuclcle  occurs,  or  while  it  is  still  small. 

The  prognosis  is  perliaps  not  so  favorable  as  in  hip  disease,  but  in 
early  cases  the  results  are  usually  excellent,  and  even  in  late  cases  much 
is  to  be  gained  from  accurate  support  to  the  spine. 

Knee. — Chronic  tubercular  disease  of  the  knee-joint,  or  tuvior  albus, 
is  most  often  made  evident  by  swelling  of  the  knee  of  a  chronic  charac- 
ter, as  a  rule  accompanied  by  pain.  The  child  is  apt  to  walk  with  the 
knee  somewhat  bent,  and  it  is  often  difficult  to  extend  it  fully.  Motion  in 
the  knee-joint  is  limited  and  the  joint  may  or  may  not  contain  fluid.  The 
character  of  the  swelling  is  commonly  that  of  a  gelatinous  mass  involving 
the  joint  rather  than  a  mass  of  fluid  filling  it.  The  occurrence  of  bony 
enlargement  is  most  significant  as  probably  establishing  the  existence  of 
chronic  tuberculosis. 

In  the  diagnosis  much  difficulty  is  often  experienced  in  determining 
between  chronic  disease  and  sprains.  It  may  be  said  in  general  that 
chronic  sprains  in  children  are  not  very  common,  and  that  it  is  not  wise 
to  make  such  a  diagnosis  until  after  recovery  has  occurred. 

As  to  the  prognosis,  chronic  tuberculosis  of  the  knee-joint  apparently 
runs  a  much  less  severe  course  than  that  of  the  hip  or  spine,  and  is  most 
favorably  affected  by  efficient  treatment. 

Chronic  tubercular  disease  of  the  other  joints  is  characterized  by 
swelling,  more  or  less  stiffness  and  pain,  and  such  joints,  as  a  rule,  present 
the  same  symptoms  as  those  described  in  speaking  of  the  knee. 

Tubercular  Dactylitis. — Tubercular  dactylitis  is  a  tubercular  disease 
of  the  phalanges  of  the  hand  and  foot.  Usually,  the  cartilaginous  ends  of 
the  bones  are  not  affected ;  the  bone  appears  larger  in  diameter  than  is 
normal  and  is  pyriforui  in  shape.  This  enlargement  is  due  to  the  in- 
creased size  of  the  periosteum  which  forms  a  new  layer  of  bone,  and  this 
new  layer  of  bone  may  be  very  thin.  Frec{uently  the  tubercular  centre 
opens  to  the  surface  by  one  or  several  tubercular  sinuses  ;  healing  in  such 
cases  may  occur  spontaneously,  but  operation  in  advanced  cases  is  advis- 
able. A  permanent  deformity  may  arise  from  the  removal  of  the  diseased 
phalanx. 

Treatment. — The  treatment  of  joint  tuberculosis  is  essentially  me- 
chanical, and  comes  within  the  scope  of  orthopedic  surgery.   ' 

TUBERCULOSIS  OF  THE  THYROID  GLAND. 

Although  tuberculosis  of  the  thyroid  gland  may  occur  as  a  primary 
cfisease,  it  is  exceedingly  rare,  the  disease  practically  being  always  second- 
ary to  a  general  miliary  tuberculosis,  and  not  presenting  symptoms  which, 
as  a  rule,  can  enable  us  to  make  a  diagnosis  during  life.  Amyloid  de- 
generation of  the  thyroid  gland  may  occur  as  the  result  of  a  chronic 
tuberculosis,  especially  of  the  joints. 


422  PEDIATRICS. 

TUBERCULOSIS  OF  THE  THYMUS  GLAND. 
Tuberculosis  of  the  thymus  gland  may  occur  in  general  tuberculosis, 
but  is  never  primary. 

TUBERCULOSIS  OF  THE  PANCREAS. 
Tuberculosis  of  the  pancreas  may  occur  in  general  tuberculosis,  but  is 
never  a  primary  disease.     Amyloid  degeneration  of  the  pancreas  may 
occur  as  a  result  of  chronic  tuberculosis,  especially  of  the  joints. 

TUBERCULOSIS  OF  THE   SPLEEN. 

Tubercular  lesions  of  the  spleen  are  always  secondary.  They  occur 
only  in  the  form  of  small  miliary  tubercles.  Amyloid  degeneration  of  the 
spleen  may  occur  as  a  result  of  clironic  tuberculosis,  especially  of  the 
joints. 

TUBERCULOSIS  OF  THE  LIVER. 
Tubercular  lesions  of  the  liver  are  ahvays  secondary.  They  appear 
in  the  form  of  small  miliary  tubercles  and  cheesy  nodules.  Amyloid  de- 
generation of  the  liver  occurs  in  certain  cases  of  tuberculosis,  especially 
where  there  is  wasting.  Tuberculosis  is  not,  however,  a  primary  disease 
of  the  liver,  but  a  symptom  of  tuberculosis  elsewhere,  especially  of  the 
bones  and  joints,  and  is  not  so  common  in  children  as  in  adults.  Tuber- 
culosis of  the  liver  occurs  in  connection  with  general  tubercular  disease 
of  other  organs,  and  does  not  in  itself  present  any  especial  characteristic 
clinical  manifestations.  The  rare  instances  in  which  large  caseous  masses 
cause  obstruction  and,  later,  disintegration  of  the  tissues,. with  hepatic  en- 
largement and  abscess,  are  not  usually  recognized  during  life. 

TUBERCULOSIS   OF  THE  KIDNEY. 

Tuberculosis  of  the  kidney  in  children  occurs  in  two  forms  :  (1)  As  a 
miliary  tuberculosis,  the  tubercle  bacillus  being  conveyed  into  the  tissues 
by  the  blood.  This  form  rarely  reaches  any  clinical  importance.  (2)  As 
a  tuberculosis  beginning  in  the  pelvis  of  the  kidney  and  extending  from 
this  into  the  cortex.  This  form  is  by  far  the  most  serious  in  its  symptoms 
and  results.  The  detection  of  the  tubercle  bacillus  in  the  urine  in  these 
cases  is  the  only  positive  sign  of  the  disease.  The  symptoms  are  those 
of  a  pyelonephritis  represented  by  pus  in  the  urine,  an  irritable  bladder, 
and  sometimes  the  presence  of  a  tumor  or  abscess  in  the  renal  region. 
The  treatment  is  essentially  surgical.  We  have  seen  cases  which  appar- 
ently recover  without  other  treatment  than  that  of  careful  feeding  and 
hygiene  and  abundance  of  out-of-door  life.  Amyloid  degeneration  of  the 
kidney  may  occur  as  a  result  of  chronic  tuberculosis,  especially  of  the 
joints. 

TUBERCULOSIS  OF  THE  BLADDER. 

Tuberculosis  of  the  bladder  is  very  rare. 


SPECIFIC  INFECTIOUS  DISEASES.  423 

TUBERCULOSIS  OF  THE  TESTICLE. 

As  compared  with  the  frequency  of  its  occurrence  in  adults,  tubercu- 
lar disease  of  the  testicle  is  rare  in  infancy  and  childhood.  When  the 
disease  is  present  the  gland  is  considerably  swollen  and  often  nodular,  but 
rarely  very  tender.  As  the  disease  progresses  adhesions  may  form  with 
the  tissues  of  the  scrotum,  and  the  degenerated  material  may  be  dis- 
charged through  a  fistulous  tract.  General  treatment  is  indicated  if  the 
disease  is  just  starting,  but  if  it  has  already  destroyed  the  usefulness  of 
the  gland  it  is  safer  to  operate  immediately  and  remove  the  focus  of  infec- 
tion, if  the  conditions  justify  surgical  interference. 

TUBERCULOSIS  OF  THE   SKIN. 

The  cause  of  what  is  now  know^n  to  be  tuberculosis  of  the  skin 
(lupus  or  scrofuloderma)  was  for  many  years  unknown.  It  was  desig- 
nated by  various  terms  according  to  the  different  forms  which  it  assumed 
on  the  skin.  Thus,  in  one  form  it  was  called  Iwpus,  and  in  another 
scrofula.  We  now  know  that  all  these  forms  are  caused  by  the  same 
micro-organism,  the  tubercle  bacillus,  and  that  this  bacillus  may  find 
its  nidus  in  the  skin,  as  it  does  in  all  other  organs  of  the  body, — that 
is,  we  may  have  a  local  tuberculosis  of  the  skin.  The  disease  does  not 
differ  in  the  child  in  its  appearance,  its  course,  and  its  general  symptoms 
from  that  met  with  in  the  adult.  As  a  rule,  it  causes,  next  to  syphilis, 
the  greatest  destruction  of  tissue  of  any  known  disease  of  the  skin.  The 
time  of  its  appearance  varies,  but  it  is  more  common  in  adults  than  in 
children. 

Treatment. — The  treatment  is  the  same  as  in  adults.  The  funda- 
mental object  to  be  obtained  is  the  destruction  of  the  diseased  tissue. 
Where  there  is  a  small  isolated  area  which  can  be  easily  removed  by  the 
knffe,  this  method  of  treatment  should  be  employed.  We  must  remem- 
ber, however,  that  by  this  method  it  is  almost  impossible  to  avoid  re- 
movmg  the  sound  tissue  with  the  diseased,  and  that  such  good  results 
as  the  avoidance  of  unsightly  scars  are  not  obtained  so  well  by  this 
method  as  by  others.  Therefore,  when  the  tissues  are  extensively  dis- 
eased, and  areas  are  involved  where  it  is  desirable  to  avoid  scarring,  such 
as  the  face,  a  locality  w^hich  is  very  frequently  attacked  by  tuberculosis, 
the  actual  cautery  and  electro-cautery  may  preferably  be  used.  Various 
caustics,  as  the  solid  stick  of  nitrate  of  silver,  as  recommended  by  the 
Vienna  School,  have  been  found  of  much  value.  This  disease,  under  all 
circumstances,  is  very  intractable  to  treatment,  and  often  causes  great 
deformity.  Recently  good  results  have  been  obtained  by  the  therapeutic 
use  of  the  X-rays.     This  method  should  be  tried  before  resorting  to  excision. 

EPIDEMIC   CEREBRO-SPINAL   MENINGITIS. 

Epidemic  cerebro-spinal  meningitis  is  a  primary  acute  infectious  disease 
caused  by  the  diplococcus  intracellularis,  and  characterized  primarily  by 
lesions  of  the  piarachnoid  of  the  brain  and  cord. 


424  PEDIATRICS. 

Etiology. — Tlic  cases  of  eerebro-spinal  meningitis  which  have  occurred 
in  Boston  and  its  vicinity,  inctuding  our  own  cases  at  the  Children's 
Hospital,  reported  in  1895,  have  been  so  exhaustively  treated  by  Coun- 
cilman, and  Mallory  and  Wright  in  the  Report  of  the  State  Board  of 
Health  of  Massachusetts  for  1898,  that  in  the  description  of  the  disease  we 
must  acknowledge  at  once  our  indebtedness  to  these  investigators  for  the 
use  which  w^e  have  necessarily  made  of  their  w^ork. 

As,  for  the  first  time  in  the  history  of  the  disease,  the  lesions  have  been 
studied  from  the  stand-point  of  their  bacteriology,  this  work  should  be 
taken  as  the  standard  by  which  w^e  are  to  be  guided  in  the  study  of  the 
pathology,  symptoms,  diagnosis,  and  prognosis  of  the  disease. 

Cerebro-spinal  meningitis  w^as  first  recognized  and  described  by  Vieus- 
seaux  in  Geneva  in  1805.  The  first  case  which  occurred  in  America  was 
in  1909.  The  disease  may  occur  in  beasts  as  well  as  in  man,  and  has 
been  much  more  Avide-spread  and  frecjuent  in  America  than  in  Europe. 
It  is  rare  in  infancy,  but  is  more  common  in  children  than  in  adults. 
The  contagious  nature  of  the  disease  is  somewhat  doubtful.  There 
seems  to  be  a  high  degree  of  immunity  to  a  second  attack.  The  incu- 
bation is  unknowni.  The  disease  may  be  epidemic  or  sporadic.  The 
mode  of  entrance  of  the  organism  is  unknown,  but  may  possibly  be 
through  the  nose. 

Pathological  Anatomy. — Nervous  System  ;  Meninges. — The  inflammatory 
process  is  characterized  by  purulent,  sero-purulent,  and  fibrino-purulent 
exudation,  chiefly  in  the  sulci  along  the  vessels  of  the  choroid  plexus,  and 
is  usually  most  pronounced  at  the  base,  but  at  times  is  more  marked  on 
the  convexity  of  the  brain,  especially  over  the  parietal  and  occipital  lobes. 
The  meninges  of  the  cerebellum  are  always  affected.  The  meninges  of 
the  entire  brain  are  rarely  involved,  although  occasionally  large  areas  are 
included  in  the  inflammatory  process.  The  longer  the  duration  of  the 
disease  the  more  extensive  are  the  lesions.  In  the  very  chronic  cases 
oedema  and  general  thickening  of  the  meninges  are  the  characteristic 
-features  of  the  lesions. 

The  inflammation  is  confined  chiefly  to  the  piarachnoid ;  the  dura  is 
but  slightly  involved,  and  the  subdural  space  is  increased  by  the  fluid 
exudate. 

In  the  most  acute  cases,  in  which  the  macroscopic  changes  are  very 
slight,  the  lesions  are  shown  by  microscopic  examination  to  consist  chiefly 
of  purulent  infiltration  of  the  meninges,  with  injection  of  the  blood- 
vessels. The  polynuclear  leucocytes  are  massed  in  some  places,  scattered 
in  others,  and  with  but  little  fibrin  among  them.  The  absence  of  eosino- 
philic cells  is  notable.     There  is  no  evidence  of  proliferation  of  tissue. 

In  the  more  advanced  cases,  on  the  other  hand,  there  are  large  num- 
bers of  cells,  chiefly  polynuclear  leucocytes,  lying  in  the  dilated  lymph- 
spaces  of  the  tissue.  The  presence  of  red  blood-corpuscles  is  rare.  The 
fibrin  is  present  in  considerable  amount,  often  showing  hyaline  changes. 


SPECIFIC    INFECTIOUS   DISEASES. 


425 


but  is  never  so  great  as  in  the  meningitis  produced  by  the  pneumococcus. 
Large  epithelioid  cells,  from  two  to  eight  times  the  diameter  of  a  leuco- 
cyte, and  filled  with  leucocytes,  or  rarely  with  lymphoid  cells,  are  often 
seen,  but  their  origin  is  obscure.  The  vessels  are  dilated,  and  at  times 
contain  thrombi.  Proliferative  changes  within  the  intima  of  the  arteries, 
which  are  common  in  tubercular  or  pneumococcus  meningitis,  are  rarely 
found. 

In  the  acute  cases  the  macroscopic  and  microscopic  changes  in  the 
meninges  of  the  cord  are  very  similar  to  those  of  the  brain.  The  cord  is 
always  somewhat  affected,  and  occasionally  to  a  greater  degree  than 
the  brain.     The  injection  of  the  dura  is  especially  intense.     The  fluid  in 

Fifi.  106. 


Showing  extreme  Opisthotonos  in  a    ease  of  Chronic  Cerebro-spinal  Meningitis.    The  hands  of  the 
attendant  are  only  steadying  the  body. 


the  subarachnoid  space  is  greatly  increased ;  it  is  cloudy  and  contains 
flocculi  of  fibrin  and  pus.  As  a  rule,  the  dorsal  and  lumbar  cords  are 
more  extensively  involved  than  the  cervical  portion.  In  the  chronic 
cases  the  meninges  of  the  cord  show  the  same  oedema  and  thickening  as 
those  of  the  brain. 

Brain  and  Cord  Tissues. — Lesions  of  the  tissue  of  the  brain  and  cord, 
as  a  rule,  cannot  be  determined  without  careful  microscopic  examination. 
They  are  more  marked  in  the  prolonged  or  chronic  cases.  They  are 
represented  chiefly  by  slight  dilatation  of  the  ventricles  with  cloudy  fluid, 
by  dilatation  of  the  vessels  of  the  ependyma  and  choroid  plexus,  and  by 
an  accumulation  of  pure  pus  or  pus  and  fibrin  in  the  posterior  cornua  of 
the  lateral  ventricles.  The  consistency  of  the  brain-substance  is  gener- 
ally but  little  altered,  but  is  softer  than  usual,  owing  to  the  oedema  and 
dilatation  of  the  ventricles.  Sometimes  areas  of  softening  and  punctiform 
hemorrhages  may  occur.  All  the  blood-vessels  of  both  the  gray  and 
white  matter  are  injected.     In  the  cord  the  congestion  of  the  vessels  and 


426  PEDIATRICS. 

the  diminished  consistency  of  its  tissue  are  the  chief  lesions.  The  cord  is 
always  less  affected  than  the  brain.  Proliferative  changes  in  the  neuroglia 
are  among  the  most  characteristic  microscopic  lesions  in  the  brain  tissue, 
but  are  rarely  found  in  the  cord.  Degenerative  lesions  in  the  ganglion 
cells  are  usually  present,  especially  in  the  very  chronic  cases. 

Xen-es  and  Ganglia. — All  of  the  cranial  nerves  are  affected,  but  the 
second,  fifth,  seventh,  and  eighth  are  most  extensively  involved.  They 
are  reddened,  oedematous,  and  infiltrated  with  the  purulent  exudation 
which  often  follows  the  nerves  to  their  foramina.  The  spinal  nerves  are 
also  mvolved,  and  their  roots  lie  embedded  in  the  exudation.  The  spinal 
ganglia  are  injected  and  oedematous.  Degenerative  changes  in  the  nerve- 
fibres  are  common. 

The  inflammatory'  process  may  extend  along  the  optic  nerve  and  pro- 
duce a  purulent  inflammation  of  the  orbit  or  eye  ;  by  extension  along  the 
fifth  nerve  it  may  produce  a  degeneration  or  destruction  of  nerve-cells  of 
the  Gasserian  ganglion,  and  by  extension  along  the  auditor}'  nen'e  it  may 
cause  lesions  of  the  internal  ear,  with  or  without  acute  inflammation  of 
the  middle  ear. 

The  Lungs. — The  lesions  m  the  lungs  occurring  in  the  course  of  an 
epidemic  cerebro-spinal  menmgitis  van'  from  a  simple  congestion  with 
oedema  to  areas  of  broncho-pneumonia  associated  with  general  bronchitis, 
or  there  may  be  a  characteristic  croupous  pneumonia  due  to  the  pneumo- 
coccus.  In  a  certain  proportion  of  cases  the  pulmonar}'  lesions  are  due 
to  the  diplococcus  intracellularis,  which  enters  the  lungs  and  produces  a 
focal  pneumonia  characterized  by  especial  anatomical  conditions.  Hemor- 
rhagic oedema  is  found  in  the  periphery  of  the  foci,  which  varj'  m  size 
from  that  of  a  pea  to  lai^e  areas  of  consolidation,  which  closely  resemble 
an  acute  croupous  pneumonia,  even  to  the  presence  of  a  fibrinous  exuda- 
tion on  the  pleura.  On  section  of  such  an  area,  numbers  of  irregular 
grayish  foci  with  softened  centres  and  hemorrhagic  and  oedematous  tissue 
between  them  are  found.  The  central  areas  represent  a  purulent  infil- 
tration of  the  tissue  T\ith  abscess  formation.  The  foci  of  consolidation 
are  not  bronchial  m  origin.  The  infection  of  the  lungs  by  the  diplococ- 
cus is  probably  by  means  of  the  blood  rather  than  of  the  bronchi,  and 
may  occur  in  almost  any  period  of  the  disease.  In  all  these  cases  im- 
mense numbers  of  diplococci  are  found  within  the  pus-cells. 

Spleen. — ^The  size  of  the  spleen  is  generally  smaller  than  in  most  of 
the  acute  diseases,  although  there  is  considerable  variation.  The  increase 
in  size  is  due  chiefly  to  hj'persemia.  There  is  very  little  change  m  the 
histological  appearances  of  the  spleen. 

Lymphatic  Xodes. — There  is  usually  no  enlargement  of  the  lymphatic 
nodes  except  in  the  complicated  cases,  and  there  are  no  microscopic 
changes  beyond  the  injection  of  the  blood-vessels. 

Liver. — The  liver  is  usually  pale  and  cloudy  on  section,  and  in  some 
cases  there  is  slight  increase  in  the  fibrous  tissue  with  cellular  infiltration. 


SPECIFIC   INFECTIOUS   DISEASES.  427 

Kidneys. — The  kidneys  show  acute,  degenerative  lesions  in  all  cases, 
but  a  nephritis  is  rare  if  the  meningitis  is  uncomplicated. 

SUn. — Lesions  of  the  skin  are  rare  ;  when  present,  they  are  in  the 
nature  of  ecchymoses  with  intense  congestion  of  the  surrounding  vessels, 
and  with  some  infiltration  with  pus-cells  beneath  the  epithelium. 

In  addition  to  the  parenchymatous  degeneration  of  the  heart,  liver,  and 
kidneys,  there  are  a  certain  number  of  other  secondary  lesions  frequently 
met  with,  such  as  subserous,  punctate  hemorrhages  in  the  endocardium, 
hyaline  and  granular  degeneration  in  the  voluntary  striated  muscles,  occa- 
sionally multiple  abscesses  in  various  parts  of  the  body,  suppurative  in- 
flammation of  the  joints,  and  choroiditis. 

The  lesions  are  essentially  the  same  in  the  epidemic  and  sporadic 
cases  of  cerebro-spinal  meningitis. 

Types  of  the  Disease. — There  are  certain  types  of  epidemic  cerebro- 
spinal meningitis  which  differ  so  markedly  as  to  deserve  special  mention. 
The  cases  may  be  either  acute  or  chronic.  The  acute  cases  are  those  in 
which  active  symptoms  last  for  about  fifteen  days,  and  two  other  forms 
may  be  recognized, — the  mild  and  the  fulminating. 

Mild  Form. — The  mild  form  occurs  more  frequently  in  children  than 
in  adults.  It  has  an  acute  onset,  short  course  of  one  or  two  days,  and 
rapid  subsidence.  These  cases  are  sometimes  called  "abortive,'"  but 
have  not  been  verified  as  yet  by  lumbar  puncture. 

Fulminating  Form. — This  term  is  restricted  by  Councilman  to  those 
cases  which  are  fatal  within  forty-eight  hours  from  the  onset  of  the  disease. 

Chronic  Cases. — The  chronic  cases  are  those  represented  by  less  active 
onset,  by  remissions  and  exacerbations,  and  long  duration. 

Intermittent  Forms. — ^These  cases  are  chronic  in  type,  and  are  seen  in 
those  instances  in  which,  with  or  without  abatement  of  the  other  symp- 
toms, there  are  complete  intermissions  in  the  temperature. 

Symptoms. — The  chief  symptoms  are  those  connected  with  the  nervous 
system,  such  as  vomiting,  delirium,  coma,  paralysis,  pain,  retraction  of 
the  neck,  opisthotonos,  and  the  mental  condition  after  the  attack ;  also 
those  symptoms  connected  with  the  lung,  with  the  skin,  the  eye,  the  ear, 
the  nose,  the  throat,  and  the  joints ;  also  the  pulse  and  temperature, 
and  the  condition  of  the  blood  and  spinal  fluid.  In  some  cases  the  onset 
is  not  so  sudden,  and  difficulties  have  arisen  in  the  differentiation  from 
typhoid  fever  and  pneumonia ;  but.  except  in  the  rather  rare  meningeal 
types  of  these  latter  diseases,  the  diagnosis  will  in  a  few  days  become  clear. 

In  young  infants  the  symptoms  of  cerebro-spinal  meningitis  may  be 
merely  a  heightened  temperature  with  clonic  convulsions,  so  that  the 
diagnosis  cannot  be  made  during  life  from  the  various  forms  of  reflex 
convulsions  which  may  occur  at  this  age,  and  cerebro-spmal  menmgitis 
can  only  be  suspected.  General  infection  by  the  diplococcus  intracellu- 
laris  is  unknown.  The  mild  cases  may  subside  in  a  few  days  ;  the  acute 
cases  may  last  for  a  number  of  weeks,  and  are  often  fatal.     Some  cases 


428  PEDIATRICS. 

are  so  very  sudden  and  violent  in  Iheir  developnient  lliaL  Ihey  resemble  a 
general  toxic  infection,  and  rapidly  prove  fatal  in  even  a  few  hoiu's  (fon- 
droyant).  Some  cases  show  decided  intermissions  in  intervals  of  several 
days,  during  which  the  child  seems  much  better,  the  temperature  is  nor- 
mal or  slightly  raised,  and  the  pain  and  tenderness  are  much  diminished. 
The  symptoms  then  return.  Marked  emaciation  occurs  in  these  cases. 
In  some  cases  after  the  usual  acute  onset,  an  intermission  may  come,  of  a 
much  longer  interval  of  weeks,  as  to  the  severe  symptoms  and  the  fever ; 
but  the  other  symptoms  are  apt  to  continue,  and  the  disease  may  assume 
a  chronic  form,  lasting  three  or  four  months. 

Vomiting. — Vomiting  is  a  very  common  symptom,  and  may  from  its 
constancy  become  a  dangerous  one.  It  may  occur  early  or  late  in  the 
disease,  and  is  due  to  direct  or  reflex  irritation  of  the  vomiting  centre, 
being  regarded  as  of  cerebral  origin. 

Delirium. — Delirium  is  a  common  symptom ;  it  may  occur  early  or 
late  in  the  disease,  may  be  violent  or  moderate,  continuous  or  intermit- 
tent, not  more  frequently  present  in  the  fatal  cases  than  in  those  w'hich 
recover,  and  does  not  always  correspond  to  an  increase  of  temperature  or 
to  an  aggravation  of  the  other  symptoms. 

Fain. — Pain,  especially  in  the  head,  is  a  very  common  symptom,  and 
is  at  times  violent.  It  may  be  located  either  in  the  occipital  or  frontal 
regions,  and  may  extend  down  the  back.  In  some  cases,  especially  in 
children,  there  are  abdominal  pains  and  also  pains  in  the  extremities. 
An  almost  constant  symptom  is  hypersesthesia  of  the  skin ;  the  patients 
do  not  like  to  be  touched,  and  often  the  least  jarring  of  the  bed  causes 
intense  pain.  According  to  Councilman,  the  general  pain  in  the  head  is 
due  to  the  inflammation  of  the  meninges.  The  pain  in  the  cervical 
region  and  back  may  be  referred  to  pressure  exerted  on  or  inflammation 
of  the  posterior  nerve-roots. 

Coma. — There  are  great  variations  in  the  cerebral  symptoms  :  there 
may  be  stupor,  drowsiness,  or  deep  coma,  varying  from  day  to  day  or 
from  hour  to  hour ;  insensibility  may  suddenly  change  to  consciousness. 
Coma  may  occur  in  the  beginning,  and  the  comatose  condition  may  con- 
tinue until  death. 

Neck  and  Spine. — Symptoms  connected  with  the  neck  are  almost 
always  present,  and  vary  from  a  simple  stiffness  to  rigidity  of  various 
degrees,  with  or  without  retraction.  Attempts  to  move  the  head  are 
usually  painful.  The  retraction  of  the  neck  is  sometimes  accompanied 
by  opisthotonos,  and  all  these  symptoms  can  be  referred  to  the  effect  of 
pressure  on  or  inflammation  of  the  spinal  nerve-roots. 

Paralysis. — According  to  Bullard,  these  cases,  while  at  times  and  in 
certain  stages  precisely  resemblmg  cases  of  paralysis  occurring  in  anterior 
poliomyelitis,  are  to  be  distinguished  clinically  from  the  paralyses  of  this 
disease  by  the  following  conditions  : 

1.  In  cases  of  paralysis  following  cerebro-spinal  meningitis  we  find 


SPECIFIC    INFECTIOUS    DISEASES.  429 

that  pain  on  passive  motion  of  tlie  limbs  persists  to  a  degree  rarely,  if 
ever,  found  in  anterior  poliomyelitis.  Such  pain  and  tenderness  sometimes 
exist  during  the  acute  stage  of  anterior  poliomyehtis  for  two  or  three  days, 
but  if  they  last  longer  than  a  week  the  case  is  one  in  which  the  diag- 
nosis is  to  be  very  carefully  considered.  It  is  not  uncommon,  on  the  other 
hand,  for  great  pain  on  passive  motion  of  the  limbs  or  of  certain  joints, 
especially  of  the  ankles,  to  exist  in  cerebro-spinal  meningitis  for  one,  two, 
or  more  months  after  the  acute  stage  of  the  disease  has  ceased.  Tender- 
ness on  pressure  over  the  muscles  also  persists  much  longer  than  in  an- 
terior poliomyelitis,  where  it  rarely  continues  much  beyond  the  acute 
stage,  but  does  not  last  as  long  as  the  pain  on  motion,  active  or  passive. 

2.  The  character  of  the  paralysis  also  differs,  at  least  in  the  early 
stages,  although  later  it  is  often  nearly  indistinguishable.  There  is  always 
a  tendency  to  spastic  contracture  in  the  early  stages  of  the  paralysis  of 
cerebro-spinal  meningitis.  This  is  sometimes  so  marked  that  it  is  evident 
on  casual  examination.  Certain  portions  of  the  limbs  are  flexed,  and 
there  is  a  decided  muscular  resistance  to  passive  motion  due  to  a  perma- 
nent tonic  contraction.  More  often,  and  particularly  in  the  later  stages, 
this  tonic  or  spastic  condition  is  not  so  evident,  and  shows  itself  only  or 
principally  in  the  extreme  degree  of  flexion  at  the  ankle-joint,  the  foot 
often  being  in  a  position  of  equinus,  and  its  axis  almost  in  direct  continu- 
ance with  that  of  the  leg. 

3.  The  knee-jerk  is  usually  less  affected  than  in  anterior  poUomye- 
litis.  In  other  words,  there  seems  to  be  a  greater  tendency  to  retain  the 
knee-jerk.  This  is  rather  a  question  of  degree  than  of  anything  else,  and 
may  have  been  accidental  in  Bullard's  patients ;  he  lays  stress  on  it  only 
in  connection  with  other  symptoms.  The  knee-jerk  is  sometimes  in  this 
affection,  as  in  anterior  poliomyelitis,  totally  abolished. 

4.  In  addition  to  these  clinical  signs  we  have  the  history  of  the  initial 
attack  to  guide  us.  While  certain  cases  occur  in  which  it  is  difficult  to 
determine  the  character  of  the  initial  attack,  as  a  rule,  the  existence  of 
retraction  of  the  head  and  of  contractures  of  the  muscles  of  the  back  or 
limbs,  the  continued  presence  of  extreme  tenderness  or  pain  on  movement, 
and  the  duration  of  the  acute  stage  of  the  disease,  enable  us  to  determine 
more  or  less  accurately  the  character  of  the  disease. 

Any  case  is  suspicious  m  which  the  acute  stage  lasts  more  than  seven 
days. 

Lungs. — Although  instances  of  pneumococcus  pneumonia  are  quite 
often  met  with  in  connection  with  meningitis,  and  sometimes  with  diplo- 
coccus  meningitis,  yet  it  will  probably  be  found  in  the  future  that  the 
meningitis  which  accompanies  pneumococcus  pneumonia  is  a  pneumo- 
coccus meningitis,  while  in  the  epidemic  meningitis  the  complicating  pneu- 
monia is  caused  by  the  diplococcus  intracellularis.  This  view  is  especially 
upheld  by  Leichtenstem,  who  states  that  while  epidemic  meningitis  is  rare 
in  many  countries,  occurs  chiefly  in  early  life,  and  has  no  crisis,  pneu- 


430  PEDIATRICS. 

monia  is  common  all  over  the  world,  at  all  ages,  and  has  a  distinct  crisis. 
The  complications  of  the  two  diseases  are  different.  Multiple  synovitis 
and  affections  of  the  eye,  so  frequent  in  epidemic  meningitis,  are  rare  in 
pneumococcus  meningitis.  The  exudation  is  more  fibrinous  in  the  latter 
disease,  and  the  result  usually  rapidly  fatal,  while  the  epidemic  form  is 
frequently  recovered  from.  The  remissions  and  exacerbations,  varying 
course,  relapses,  and  uncertain  gait  belong  exclusively  to  the  epidemic 
form.  Leichtenstern  also  believes  that  the  cerebral  symptoms  dependent 
on  a  pneumococcus  pneumonia  subside  at  the  time  of  the  crisis,  just  as 
the  other  symptoms  do.  The  diplococcus  intracellularis  can  enter  the 
lung  and  produce  a  focal  pneumonia  characterized  by  especial  anatomical 
features,  and  occurring  in  both  the  acute  and  chronic  cases. 

SJcin. — The  lesions  of  the  skin  gave,  in  the  earlier  epidemics,  the  name 
of  spotted  fever  to  the  disease.  These  lesions  vary  greatly,  and  may  be 
represented  by  petechise.  larger  hemorrhagic  foci,  or  circumscribed  areas 
of  hyperaemia ;  the  most  common  form  of  efflorescence  is,  however,  herpes. 
In  numbers  of  cases  tliere  are  no  lesions  of  the  skin  whatever.  A  tache 
cerehrale  is  of  common  occurrence. 

Eye. — Symptoms  connected  with  the  eye  are  promment  in  epidemics 
of  meningitis,  and  there  is  a  marked  tendency  for  the  infection  to  extend 
along  the  optic  nerve,  as  already  descril^ed  in  the  pathology.  The  cause 
of  the  lesions  (neuritis  or  degeneration  of  the  nerves  of  the  eye)  may  be 
due  to  their  involvement  in  the  exudation  at  the  base  of  the  brain  without 
any  extension  of  the  inflammatory  process  to  either  the  orbit  or  the  eye. 
Or  the  optic  nerves  may  also  be  involved  in  this  exudation.  Again,  the 
inflammation  from  the  meninges  may  extend  directly  from  the  brain 
into  the  eye  by  means  of  the  piarachnoid.  All  of  the  cases  of  purulent 
choroido-iritis  and  the  very  rare  cases  of  suppuration  in  the  orbit  are 
probably  due  to  such  extension.  There  is  no  metastasis  in  these  con- 
ditions, but  a  direct  extension.  A  third  cause  of  the  lesions  of  the  eye, 
and  one  to  which  most  of  the  cases  of  keratitis  are  due,  is  a  neuritis  of 
-the  fifth  nerve,  with  destruction  of  the  Gasserian  ganghon  and  a  loss  of 
sensation. 

The  pupils  are  generally  altered.  Reaction  to  light  is  slow  and  in- 
complete, and  dilatation  is  very  apt  to  occur.  Paralysis  of  the  ocular 
muscles  with  resulting  strabismus  may  develop,  but  the  paralysis  is 
often  temporary,  and  different  muscles  may  be  affected  at  different  times. 

Ear. — As  in  the  eye,  so  in  the  ear,  the  infection  may  extend  along  the 
auditory  nerve.  There  may  be  pain,  tenderness  of  the  mastoid,  and  deaf- 
ness ^^ith  or  without  otitis  media.  The  lesions  in  epidemic  meningitis  are 
always  secondary  and  are  due  to  extension  from  the  brain,  while  when 
the  meningitis  is  secondary  to  an  otitis  media  the  organism  of  infection  is 
the  pneumococcus  or  streptococcus.  These  lesions  of  the  ear  are  the 
most  common  complications  of  epidemic  meningitis,  and  in  a  large  num- 
ber of  cases  deafness  results. 


SPECIFIC    IXFECTIOUS   DISEASES.  431 

iVb.se  and  Throat. — Acute  coryza  and  inflammation  of  the  throat  may 
occur.  The  lesions  may  be  due  to  a  primary  extension  from  the  brain  or 
from  a  direct  secondary  infection  from  the  ear.  Tliese  questions,  how- 
ever, have  not  yet  been  satisfactorily  determined,  and  it  is  possible  that 
the  diplococcus  intracellularis  may  be  found  in  the  nasal  secretion  of 
patients  without  meningitis. 

Joints. — Acute  inflammation  of  the  joints  is  frequent  in  epidemic 
meningitis.     The  knees  are  the  joints  most  commonly  affected. 

Pulse  and  Temperature. — A  marked  characteristic  of  epidemic  cerebro- 
spinal meningitis  is  the  inequality  of  the  pulse  and  temperature.  The 
pulse  may  often  remain  normal  while  the  temperature  is  heightened,  and 
there  is  no  relation  between  the  height  of  the  temperature  and  the  se- 
verity of  the  sjmiptoms.  The  temperature  rarely  reaches  40°  C.  (104° 
F.),  and  varies  from  39°  C.  (102.2°  F.)  to  38°  C.  (100.4°  F.).  The  type 
is  often  remittent.  The  fever  gradually  disappears  and  the  temperature 
cun'e  is  interrupted  by  irregular  rises  and  falls.  A  terminal  rise  of  tem- 
perature occurs  in  some  cases.  The  pulse  shows  the  same  irregularity  as 
the  temperature,  and  may  range  from  70  to  130  in  a  mmute.  Relative 
slowness  of  the  pulse  to  the  temperature  is  often  found  in  children.  Ab- 
solute slowness  of  the  pulse  is  not  common. 

Blood. — Leucocytosis  is  usually  present.  The  leucocytes  gradually 
diminish  towards  the  end  of  the  disease  in  the  cases  which  recover.  lodo- 
philia  is  generally  marked. 

Spinal  Fluid. — In  cerebro-spinal  meningitis  the  character  of  the  fluid 
is  more  or  less  turbid,  and  in  severe  acute  cases  a  puriform  deposit  fre- 
quently settles  to  the  bottom  of  the  test-tube  in  a  short  time ;  there  are 
numerous  polymorphonuclear  leucocjdes  (pus-corpuscles)  and  occasional 
smaller  mononuclear  lymphoid  cells  and  fibrin.  Groups  of  the  diplococcus 
intracellularis  are  found  in  vanning  numbers  in  the  protoplasm  of  some  of 
the  leucocjdes.  The  fluid  should  be  withdrawn  at  the  time  when  the  active 
symptoms  are  present,  or  the  growth  of  the  organism  may  fail  to  be  ob- 
tained. A  microscopic  examination  is  necessary  in  all  cases,  as  the  macro- 
scopic appearance  of  the  fluid  is  not  to  be  relied  on.  Inoculation  experi- 
ments are,  as  a  rule,  unsuccessful,  as  the  organism  is  not  pathogenic  for 
guinea-pigs.     Goats  are  susceptible  to  it. 

Mental  Condition  after  Recovery. — In  some  cases  after  recovery  from 
the  acute  symptoms  a  condition  of  mental  impairment  remains. 

Diagnosis. — The  difl'erential  diagnosis  of  cerebro-spinal  meningitis  is 
essentially  from  other  forms  of  meningitis,  whether  tubercular  or  non- 
tubercular.  The  sudden  onset,  extreme  headache,  hypersesthesia.  opis- 
thotonos, rigidity  and  retraction  of  the  neck,  pain  and  tenderness  of  the 
neck  and  spine,  herpes,  moderate  temperature  in  comparison  with  the 
severity  of  the  symptoms,  and  rapid  development  of  apathy  and  coma  in 
keeping  with  the  early  exudation  of  pus  over  the  surface  of  the  brain,  are 
in  strong  contrast  to  the  slow  onset  and  gradual  development  of  the  symp- 


432  PEDIATRICS. 

toins  in  tubercular  meningitis,  described  on  page  409.  The  non-tubercular 
forms  of  acute  meningitis  are  more  difficult  to  differentiate,  and  the  only 
exact  means  of  diagnosis  is  by  lumbar  puncture.  Epidemic  influenza  at 
times  simulates  epidemic  cerebro- spinal  meningitis  so  closely  that  the  dif- 
ferential diagnosis  can  only  be  made  by  spinal  puncture. 

Prognosis. — The  prognosis,  when  the  child  is  young  and  the  onset  is 
violent,  with  high  temperature  and  continuous  convulsions,  is  very  serious. 
as  the  disease  is  one  of  the  most  fatal  in  childhood,  and  only  about  one-h^lf 
recover  (Sachs):  but  even  in  the  apparently  fatal  cases  when  coma  has 
intervened,  a  change  may  take  place  and  the  child  recover.  The  first 
two  weeks  are  usually  the  critical  period,  so  far  as  the  acute  form  of  the 
disease  is  concerned.  According  to  Sachs,  the  cases  in  which  the  coma 
develops  rapidly,  and  does  not  show  any  signs  of  receding  within  the 
first  week  or  two,  are  almost  certain  to  end  fatally.  If  the  coma  has  been 
slow  to  develop,  the  process  is  usually  less  intense  and  the  prognosis  is 
better ;  but  even  in  these  cases,  if  the  coma  remains  stationary  for  a 
week  or  more  the  chances  of  recovery  lessen  every  hour  that  the  coma 
continues. 

The  chronic  form  is  apt  to  prove  fatal,  both  from  exhaustion  and  from 
the  development  of  more  serious  central  nervous  lesions. 

The  cases  which  recover  are  often  left  with  permanent  lesions,  c-ausing 
deafness,  blindness,  various  paralyses,  and  mental  impairment.  Death  is 
very  apt  to  occur  c|uietly. 

Treatmext. — The  treatment  of  cerebro-spinal  meningitis  varies  accord- 
ing to  the  severity  of  the  symptoms.  In  most  cases  sedatives,  such  as 
the  bromides,  and  chloral,  are  indicated,  and  where  the  pain  is  severe 
opium  in  considerable  doses  is  often  needed.  The  ice-bag  or  Leiter's  coil 
applied  to  the  head,  and  absolute  quiet  in  a  darkened  room,  are  important 
adjuvants  to  the  treatment.  In  many  cases  the  pulse  becomes  so  weak 
and  the  prostration  so  marked  that  stimulants  are  required  until  conval- 
escence is  established,  when  they  can  usually  be  replaced  by  tonics.  In 
some  cases  the  hyperaisthesia  and  general  sensitiveness  to  noise,  light,  and 
motion  in  the  room  are  so  extreme  and  so  characteristic  that  the  attend- 
ants should  be  cautioned  not  to  touch  the  child  or  the  bed  unnecessarily, 
and  alDsolute  quiet  should  be  enforced  in  the  room  and  throughout  the 
house. 

The  maintenance  of  the  bodily  nutrition  is  the  most  difficult  and  yet 
the  most  important  point  in  the  treatment.  Milk  and  broths  must  be  our 
chief  reliance.  The  milk  must  be  adapted  to  the  age  and  state  of  digestion 
of  the  patient,  being  modified  according  to  the  general  principles  of  feed- 
ing. In  many  cases  the  swallowing  reflex  is  lost  early  in  the  disease  and 
forced  nasal  feeding  or  gavage  becomes  a  last  resort.  It  may,  with  skill 
and  careful  nursing,  be  continued  for  months.  We  have  had  a  case  of 
chronic  cerebro-spinal  meningitis  in  which  this  method  was  employed  at 
four  hour  intervals  for  over  six  months. 


SPECIFIC    INFECTIOUS    DISEASES.  433 

The  use  of  anti-toxin  has  recently  been  advised.  We  nave  tried  it  con- 
scientiously in  a  series  of  twenty  cases  but  were  not  impressed  by  the  re- 
sults. The  percentage  of  cures  was  not  greater  than  in  the  cases  treated 
symptomatically.  Forty-five  per  cent,  recovered.  The  anti-toxin  was 
given  in  large  doses,  in  several  cases  over  100,000  units  being  given  in  the 
course  of  the  treatment.  No  ill  effects  were  observed  from  these  large 
amounts  aside  from  the  productions  of  urticaria. 

The  following  cases  illustrate  cerebro-spinal  meningitis  ;  where,  as  in 
some  instances,  the  diplococcus  intracellularis  is  not  mentioned,  it  is  be- 
cause these  cases  occurred  before  lumbar  puncture  was  commonly  used 
for  diagnosis. 

A  boy,  thirteen  years  old,  had  never  had  any  special  diseases,  but  had  been 
rather  delicate  for  a  number  of  months.  He  went  to  a  Christmas  party  on  December 
25,  and  on  returning  from  the  party  complained  of  the  motion  of  the  sleigh  in  which 
he  rode  home.  On  the  following  day,  in  the  afternoon,  he  was  found  to  be  listless, 
to  have  his  tongue  coated  but  not  dry,  a  temperature  of  40.5°  C.  (105°  F.),  and  a  pulse 
of  140.  He  complained  of  tenderness  and  pain  in  the  back  of  his  neck  ;  there  was 
also  tenderness  in  the  abdomen.     He  appeared  to  be  somewhat  dull. 

On  the  following  day  the  temperature  in  the  morning  was  39.4°  C.  (103°  F.),  and 
the  pulse  was  120.  He  was  much  more  dull  and  apathetic  than  on  the  previous  day, 
and  in  the  afternoon  became  delirious.  In  the  evening  he  had  involuntary  passages 
of  urine  and  loose  discharges  from  the  bowels.     His  temperature  was  40°  C.  (104°  F.). 

On  the  following  day  his  temperature  was  39.4°  C.  (103°  F.),  and  the  respirations 
varied  from  40  to  80  and  were  regular.  He  was  unconscious.  Subsultus  tendinum 
was  present.  There  was  retraction  of  the  head.  The  pupils  did  not  respond  to  light, 
but  were  equal  in  size.     A  tache  cerebrale  was  present. 

On  the  evening  of  the  following  day,  four  days  from  the  onset  of  the  disease,  he 
died. 

The  autopsy  showed  the  convex  surface  of  the  entire  brain  and  cord  to  be  covered 
with  a  thick  exudation  of  pus,  the  spleen  to  be  enlarged,  and  the  case  to  be  one  of 
acute  cerebro-spinal  meningitis. 

A  child,  two  years  old,  was  brought  to  the  hospital  with  the  history  that  it  had 
been  showing  symptoms  of  malaise  for  six  weeks.  Two  weeks  previous  to  entering 
the  hospital  it  had  a  convulsion,  and  the  indefinite  and  general  symptoms  had  become 
more  pronounced.  There  had  been  loss  of  appetite,  with  constipation,  at  times 
vomiting,  slight  cough,  and  a  heightened  temperature. 

The  head  was  retracted,  and  the  muscles  of  the  neck  were  rigid.  The  eyes  were 
staring,  but  the  pupils  reacted  to  light.  There  was,  at  times,  slight  opisthotonos. 
The  abdomen  was  retracted.  The  emaciation  was  extreme,  so  that  the  vertebrpe  and 
ribs  became  quite  prominent.  The  child  was  apparently  unconscious,  and  did  not 
notice  olijects  which  were  brought  before  its  eyes,  although  the  eyes  were  open.  It 
moaned  at  times,  and  occasionally  the  legs  were  drawn  up.  No  efflorescence  was  de- 
tected anywhere  on  the  skin.  The  temperature  varied  from  36.6°  to  38°  C.  (98°  to 
100.5°  F.).  Sometimes  it  cried  out  sharply,  as  though  in  pain.  A  tache  cerebrale  was 
often  present. 

The  treatment  of  this  case  was  simply  the  frequent  administration  of  milk,  with 
the  addition  of  stimulants  when  indicated  by  the  weakness  of  the  pulse.  The  child 
was  in  so  apathetic  a  condition  that  the  use  of  any  drug  was  unnecessary.  Although 
at  times  it  cried  out  as  if  in  severe  pain,  yet  these  attacks  were  not  sufficiently  long 
to  necessitate  their  control  by  an  opiate. 


434  PEDIATllU'S. 

During  the  following  month  the  child  remained  in  very  much  the  same  condition. 
The  liead  was  retracted  at  times,  and  the  emaciation  became  extreme,  the  abdomen 
being  very  much  sunken  (boat-shaped).  In  the  next  two  weeks  the  nourishment  was 
taken  more  readily,  the  head  was  less  retracted,  and  he  began  to  notice  objects  around 
him,  but  he  vomited  once  or  twice  nearly  every  day.  The  temperature  at  this  stage 
of  the  disease  became  normal. 

One  month  later,  which  was  two  months  from  the  time  when  the  child  entered 
the  hospital,  he  Avas  able  to  sit  up  without  help.  There  was  no  retraction  of  the 
head,  but  the  muscles  of  the  neck  were  very  rigid,  and  the  head  showed  a  tendency 
to  retraction. 

During  the  following  month  the  child  continued  to  improve  slowly,  increased  in 
weight,  recovered  his  appetite,  and  when  seen  one  month  later  was  found  on  physical 
examination  to  be  in  a  normal  condition. 

The  following  case  of  epidemic  cerebro-spinal  meningitis  occurred  in 
the  service  of  Dr.  Buckingham  at  the  Children's  Hospital. 

The  child  was  two  years  and  eleven  months  old.  She  was  breast-fed  for  fifteen 
months.  At  eight  months  she  had  scarlet  fever  ;  at  eighteen  months  she  contracted 
measles.  With  these  exceptions  she  had  always  been  well  and  strong.  Two  days 
before  entrance  to  the  hospital  she  fell  and  struck  her  head.  She  complained  subse- 
quently of  headache.  The  day  before  entrance  she  vomited  several  times,  and  held 
her  hands  to  her  right  ear  as  if  in  pain.  There  was  no  history  of  disease  of  the  ears, 
of  retraction  of  the  head,  of  rigidity  of  the  neck,  or  of  convulsions. 

The  physical  examination  showed  nothing  abnormal  aside  from  a  considerable  de- 
gree of  rigidity  of  the  posterior  cervical  muscles  and  pain  wh^-n  passive  movements  of 
the  head  were  made.  There  was  some  hypertrophy  of  the  tonsils,  with  coated  tongue 
and  some  secretion  in  the  naso-pharynx.  The  temperature  was  38.8°  C.  (102°  F.),  the 
pulse  130,  and  the  respirations  32.     A  specimen  of  urine  could  not  be  obtained. 

Two  days  later  there  was  marked  retraction  of  the  head,  with  internal  strabismus. 
The  child  was  very  irritable,  and  was  evidently  very  tender  on  pressure  over  the  back  of 
the  neck.  On  the  day  after  entrance  the  ears  were  examined,  and  the  auditory  canals 
were  found  full  of  epithelial  scales,  which  were  removed,  leaving  the  drum  membrane 
and  walls  of  the  canal  reddened.  On  the  following  day  an  acute  serous  effusion  was 
noted  in  the  middle  ear.  Paracentesis  of  the  membrana  tympani  was  performed  and 
wicks  inserted. 

On  the  third  day  lumbar  puncture  was  performed.  The  cerebro-spinal  fluid  was 
cloudy,  with  slight  formation  of  fibrin.  The  cells  were  chiefly  polynuclear  leucocytes, 
"with  some  mononuclear  cells.  Occasional  organisms  were  found  within  the  cells.  Cul- 
tures from  the  fluid  showed  the  presence  of  the  diplococcus  intracellularis.  There  were 
several  single  colonies,  as  well  as  fine,  diffuse,  pin-point  growths  between,  on  the  culture- 
medium. 

For  six  days  the  temperature  gradually  declined,  and  nearly  reached  the  normal. 
The  child  sat  up  of  its  own  accord,  and  freely  moved  its  head.  There  was  no  strabis- 
mus. It  then  began  to  grow  slowly  worse.  The  temperature  rose  with  considerable 
morning  and  evening  variations,  and  for  nearly  a  month  ran  a  very  irregular  course, 
the  evening  temperature  ranging  between  39.4°  C.  (103°  F.)  and  40.4°  C.  (104.8°  F.). 
The  pulse  varied  from  120  to  146,  and  the  respirations  from  30  to  85.  The  aural  symp- 
toms disappeared,  but  the  child  grew  more  irritable  ;  retraction,  tenderness,  rigidity,  and 
strabismus  all  returned.  There  was  cough  and  an  associated  bronchitis.  There  were  no 
convulsions  or  coma.  The  child  was  quiet  but  easily  aroused.  There  was  no  general 
hyperaesthesia.  The  urine  one  month  after  entrance  was  examined  and  found  normal. 
Loss  of  weight  was  very  noticeable.  Towards  the  end  of  the  fourth  week  in  the  hos- 
pital the  temperature  began  to  fall,  the  symptoms  gradually  diminished,  the  mental  and 


SPECIFIC  INFECTIOUS  DISEASES.  435 

physical  condition  improved  steadily,  but  there  seemed  to  be  a  moderate  degree  of 
paralysis  of  the  legs,  which  was  slow  in  passing  away.  Convalescence  was  prolonged 
over  a  period  of  five  weeks,  when  the  patient  was  discharged  to  the  convalescent  home 
much  relieved,  but  with  the  legs  still  not  entirely  under  control. 

The  following  case  was  that  of  a  girl  eight  years  old,  who  represented 
that  form  of  cerebro-spinal  meningitis  which  is  designated  chronic : 

Her  parents  were  said  to  have  been  healthy,  and  there  was  no  evidence  of  tuber- 
culosis or  syphilis  in  the  family.  A  brother  whom  we  saw  in  consultation  died  of  cere- 
bro-spinal meningitis.  With  the  exception  of  an  attack  of  measles  and  of  whoop- 
ing-cough, the  child  had  not  had  any  other  diseases.  She  had  not  been  entirely 
well  since  an  attack  of  pertussis,  which  occurred  one  year  previous  to  entering  the 
hospital,  and  her  attack  of  cerebro-spinal  meningitis  had  begun  four  and  a  half 
months  previously. 

The  onset  of  the  attack  was  sudden.  She  went  to  bed  in  fairly  good  condition, 
but  woke  up  in  the  night  delirious,  screaming,  and  apparently  not  recognizing  her 
parents.  These  symptoms  continued  until  the  following  week.  There  were  no  convul- 
sions. A  week  later  vomiting  occurred  every  two  or  three  days.  This  Avas  not  de- 
pendent upon  food,  and  had  occurred  at  intervals  up  to  the  time  of  entering  the 
hospital.  The  bowels  were  constipated.  There  had  been  more  or  less  opisthotonos 
from  the  beginning  of  the  illness,  and  also  in  the  beginning  there  was  decided  retrac- 
tion of  the  head.  The  stiffness  of  the  neck  had  gradually  diminished,  but  at  times 
returned.  Up  to  the  time  of  entering  the  hospital  the  child  was  said  to  have  had 
constantly  a  heightened  temperature,  varying  from  37.7°  to  39.4°  C.  (100°  to  103° 
F.),  with  a  rapid  pulse  and  quick  respirations.  Nothing  abnormal  had  been  found  in 
the  urine.     There  had  been  no  efflorescence  on  the  skin. 

Fig.  107. 


Ghronic  intermittent  cerebro-sijinal  meningitis.    Tache  c<;r6brale  showing  on  right  thigh.    Female, 

8  years  old. 

Four  weeks  previous  to  entering  the  hospital  the  child  was  noticed  to  be  ])lind. 
This  had  occurred  suddenly.  The  child  had  had  constant  headache,  and  shortly  after 
the  beginning  of  the  attack  showed  a  loss  of  power  of  motion  in  both  legs.      At  times 


436  PEDIATRICS. 

there  had  been  incontinence  of  fa?ces  and  of  urine.  An  examination  of  the  urine 
showed  it  to  have  a  specific  gravity  of  1015,  to  be  normal  in  color,  to  have  an  acid  reac- 
tion, and  not  to  contain  albumin  or  sugar.  No  evidence  of  syphilis  was  detected. 
She  sometimes  showed  improvement  in  her  general  symptoms  and  became  conscious, 
but  she  was  unable  to  sit  up  or  to  wall:.  As  shown  in  Fig.  107,  she  was  somewhat 
emaciated. 

There  was  extreme  hyperaesthesia  of  the  body  and  extremities.      The  slightest  mo- 
tion of  the  bed  caused  discomfort  and  pain.      An  examination  of  the  thoracic  and  ab- 
dominal organs   showed  that   they   were   normal. 
Fig.  108.  The  pulse    was  80  and  regular,    the    respirations 

were  natural,  the  temperature  was  37.7°  C.  (100° 
F.).  She  sometimes  had  an  attack  characterized 
l)y  spasmodic  contractions  of  all  the  muscles  of  the 
body,  lasting  for  about  thirty  seconds.  At  these 
times  there  was  no  loss  of  consciousness,  and  the 
child  screamed  for  some  time  afterwards  as  though 
in  pain.  During  the  attacks  the  pulse  grew  feeble 
and  intermittent,  the  respirations  slow  and  super- 
Secondary  choroido-iritis  occurring  in  ficial,  and  the  extremities  cold.  Brandy  was  given 
cerebro-spinal  meningitis.  subcutaneously,    and  reaction   took   ulace.      There 

was  a  decided  tache  cerebrale. 
Fig.  108  shows  the  condition  of  her  eyes.     The  pupils  reacted,  and  the  retime  were 
evidently  sensitive  to  light,  yet  apparently  she  was  blind. 

In  the  middle  of  the  eye  was  a  yellowish  mass  with  an  irregular  border.  There 
was  a  very  slight  hyperaemia  in  the  ciliary  region.  The  iris  seemed  slightly  pushed 
forward,  and  its  pupillary  edge  was  a  little  uneven.  A  yellowish  or  yellowish-white 
reflex  appeared  from  the  fundus  of  the  eye  even  without  the  use  of  the  ophthalmoscopic 
mirror,  and  it  was  not  difficult  to  distinguish  that  this  reflex  did  not  come  from  the 
level  of  the  lens,  but  that  it  was  situated  deeper.  The  tension  of  the  eyeball  was  very 
much  reduced,  and  there  was  very  little  tenderness  on  pressure. 

These  yellowish  appearances  in  the  pupils  are  sometimes  called  pus  emboli,  and 
also  metastatic  choroido-iritis  ;  but  while  in  other  forms  of  meningitis  metastasis  may 
occur,  it  does  not  occur  in  the  epidemic  form,  Jjut  is  a  direct  extension. 

In  the  other  forms  where  it  does  occur,  both  the  meningitis  and  the  lesions  of  the 
eye  are  due  to  metastasis.  Sometimes  this  yellowish  mass  fills  the  vitreous  entirely, 
sometimes  only  in  part.     It  may  have  blood-vessels  on  its  surface. 

The  child  remained  in  about  the  same  condition  for  some  time.  At  times  she 
screamed  as  though  in  pain,  but  she  took  her  nourishment  fairly  well.  She  had  one 
slight  convulsive  attack,  which  involved  mainly  the  upper  extremities,  the  lower  ex- 
tremities being  only  slightly  contracted.  During  this  attack  her  thumbs  were  turned 
in,  her  fingers  clinched  over  them,  and  her  arms,  which  were  usually  extended  at  her 
sides,  were  flexed  at  the  elbows.  Her  face  showed  no  sign  of  spasm,  and  during  the 
attack  the  radial  pulse  was  full,  soft,  and  regular.  After  a  few  seconds  the  muscles 
again  became  relaxed,  and  there  was  no  further  tendency  to  contraction.  The  usual 
position  in  which  she  lay  during  the  following  weeks  was  with  the  thighs  slightly 
flexed  and  abducted,  and  the  legs  flexed  at  the  knee,  with  the  heels  almost  touching 
each  other.  About  two  weeks  after  entering  the  hospital  the  right  leg  became  flexed 
on  the  thigh  to  such  an  extent  that  the  knee  almost  touched  the  chin  and  the  heel 
rested  on  the  vulva.  Any  attempt  to  extend  the  leg  made  the  child  cry  out  as  though 
in  pain,  the  left  leg  being  naturally  extended  in  bed.  This  condition  of  the  right  leg 
continued  for  several  days  and  then  disappeared.  Some  days  later  a  slight  convulsive 
attack  took  place,  which  seemed  to  affect  the  right  side  more  than  the  left. 

The  temperature  during  the   eighteen  days  when  the   child  was  in  the  hospital 


SPECIFIC  INFECTIOUS  DISEASES.  437 

varied  from  37°  to  38.8°  C.  (98°  to  102°  F.).  The  pulse  during  this  time  varied 
from  68  to  100  ;  the  respirations  sometimes  varied  from  34  to  52,  hut  were  usually 
ahout  28. 

The  fingers  were  flexed  most  of  the  time,  and  there  was  so  much  rigidity  of  the 
limbs  that  the  reflexes  could  not  be  satisfactorily  determined.  Later  in  the  disease 
there  was  slight  cyanosis  of  the  cheeks  and  lips,  and  an  eruption  of  milia  on  the 
chest  apparently  arising  from  her  continually  perspiring  day  and  night.  She  lay  in  a 
stupor  all  the  time,  except  when  she  was  moved,  when  she  would  cry  out.  She  showed 
no  signs  of  understanding  anything  that  was  said  to  her.  Sometimes  she  would  be 
seized  with  an  attack  of  rapid  breathing  lasting  several  hours.  The  bowels  had  been 
constipated  at  first,  but  later  diarrlioea  occurred.  There  was  incontinence  of  faeces  and 
urine,  but  no  vomiting.  The  teeth  were  kept  closed,  and  had  to  be  forced  apart  when 
she  was  fed.  Once  slie  had  a  convulsion,  in  which  the 
head    was    drawn   back,    the    body  and    extremities   were  Pig.  109, 

rigid,  and  the  eyes  rolled  up. 

Eighteen  days  after  entering  the  hospital  the  child  was 
taken  to  her  home,  so  that  the  daily  record  could  not  be 
obtained. 

An  examination  made  two  weeks  after  she  left  the 
hospital  showed  a  spastic  condition  of  the  extremities  and 
neck. 

When  seen  by"  Dr.  Bullard  at  this  time  the  child  took 
no  notice  of  her  surroundings,  and  her  eyes  when  opened 
had  a  vacant  expression,  due  largely  to  the  mental  condi- 
tion, although  she  was  undoubtedly  blind.  The  extremi- 
ties were  much  wasted,  and  were  all  in  a  condition  of 
spastic  rigidity.     There  was  slight  flexion  of  the  thighs  on 

the  body  and  of  the  legs  on  the  thighs,  while  the  feet  were     .  Chronic  cerebro-spinai  men- 

•'  ^  o      '  mgitis.     Spastic  condition  of 

extended  in  neariy  a  straight  line  with  the  legs.  hand  five  and  a  half  months 

The  hand,  as  shown  in  Fig.  109,  was  flexed  almost  at     after  onset  of  the  disease. 
right  angles  to  the  wrist.     The  proximal  phalanges  of  the 

fingers  were  hyperextended,  while  the  other  plialanges  Avere  flexed.  The  thumb  was 
strongly  adducted,  and  its  distal  phalanx  was  flexed. 

This  is  a  position  of  the  hand  frequently  found  in  the  later  stages  of  spastic  paral- 
ysis, and  is  due  to  the  preponderant  contraction  of  the  flexors  of  the  wrist  and  weak- 
ness of  the  interossei  and  lumbricales. 

The  child  gradually  grew  weaker,  and  died  of  exhaustion  a  few  weeks  later. 

The  following  case  was  seen  in  consultation  with  Dr.  Townsend  : 

A  boy,  four  and  a  half  years  old,  had  been  previously  well,  with  the  exception  of 
an  attack  of  measles  when  he  was  one  year  old. 

On  May  9  he  was  suddenly  attacked  with  vomiting,  which  continued  at  intervals 
for  two  days.  From  the  beginning  of  the  attack  he  complained  of  severe  pain  in  the 
head  and  abdomen.  On  the  second  day  of  the  attack  there  was  much  contraction  of 
the  head,  and  he  was  slightly  delirious,  although  rational  most  of  the  time.  The 
temperature  was  raised  from  the  beginning  of  the  attack.  There  were  no  convulsions. 
The  bowels  were  not  moved  during  the  first  week  of  the  disease.  When  first  seen  by 
Dr.  Townsend  the  pulse  was  124  and  regular,  the  temperature  38.8°  C.  (102°  F.),  and 
the  respirations  20  and  regular.  There  was  slight  opisthotonos.  There  were  no  con- 
tractions of  the  muscles  of  the  limbs.  The  symptom  of  Kernig  was  present.  There 
was  no  tenderness  along  the  spine.  The  cutaneous  sensibility  was  everywhere 
normal.     There  were  no   cutaneous   efflorescences  or  ecchymoses.     The  pupils  were 


438 


PEDIATRICS. 


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regular  and  reacted  normally  tu  lighl.  There  was  no 
strabismus  or  photophobia.  Nothing  abnormal  was  de- 
tected on  physical  examination.  The  child  was  appar- 
ently in  great  pain,  cried  out  a  great  deal,  and  moaned 
continually.  The  suffering  during  the  next  few  days 
was  so  great  that  morphine  in  doses  of  0.002  gramme 
(bV  grain)  had  to  be  given.  This  dose  had  to  be  in- 
creased so  frequently  that  it  was  found  that  the  child 
took  0.015  gramme  (^  grain)  before  relief  was  obtained. 
Applications  of  ice  to  the  head  and  spine  gave  no  relief, 
and  for  a  number  of  days  it  was  found  that  there  was 
needed  to  control  the  restlessness  and  pain  0.01  to  0.02 
gramme  (|  to  ^  grain)  of  morphine  during  the  twenty- 
four  hours. 

On  the  twenty-fourth  day  of  the  disease  the  temper- 
ature, which  had  varied  from  37.7°  to  39.4°  C.  (100°  to 
103°  F.),  became  normal,  remaining  so  until  the  forty- 
seventh  day.  During  this  time  the  head  was  only 
slightly  retracted,  and  the  child  seemed  free  from  pain, 
but  remained  in  a  very  listless  condition,  not  speaking, 
and  taking  but  little  nourishment  or  stimulants.  He  be- 
came emaciated,  passed  his  urine  and  faeces  involuntarily, 
and  occasionally  vomited.  Nutritive  enemata  were  not 
retained,  but  on  the  forty-first  day  of  the  disease  pepto- 
nized milk  was  retained,  and  on  the  forty-sixth  day  he 
was  able  to  take  gruel,  and  at  that  times  talked  and 
laughed. 

On  the  forty-seventh  day  of  the  disease  a  relapse 
occurred,  the  temperature  rising  to  39.7  C.  (103.6  F.). 
The  head  was  rigidly  drawn  back,  the  eyes  were  staring, 
and  the  pain  returned.  The  symptom  of  Kernig,  which 
had  never  disappeared  entirely,  again  became  well 
marked.  At  this  time  I  saw  the  child  with  Dr.  Town- 
send.  On  the  sixty-sixth  day  of  the  disease  the  con- 
vulsive movements  of  the  left  arm  and  leg,  with  turning  ' 
in  of  the  left  eye,  occurred.  Several  days  previous  to 
this  relapse  a  number  of  sudamina  appeared  on  the 
neck  and  trunk,  and  an  evanescent  erythematous  erup- 
tion on  the  neck  and  face,  lasting  only  a  few  hours. 
From  the  sixty-first  to  the  sixty-sixth  day  of  the  disease 
his  body  was  covered  with  a  macular  efflorescence,  the 
macules  varying  in  size.  Ecchymoses  were  at  no  time 
seen,  and  repeated  examinations  of  the  chest  and  abdo- 
men showed  nothing  abnormal. 

From  the  seventy-first  day  to  the  seventy-third  day 
the  temperature  was  again  normal,  the  child  took  his 
food  well,  the  neck  was  straight,  and  his  general  appear- 
ance was  encouraging. 

On  the  seventy-fourth  day  he  again  had  convulsive 
movements,  most  marked  on  the  left  side  of  the  body. 
The  head  was  drawn  back,  and  at  noon  the  next  day  his 
temperature  was  39.4°  C.  (103°  F.).  The  pulse,  which 
during  the  entire  illness    ranged  from  120  to  140  and 


SPECIFIC   INFECTIOUS   DISEASES.  439 

had  previously  been  regular,  was  now  at  times  irregular  and  intermittent.  The  bowels 
were  constipated  at  this  time. 

After  this,  although  the  temperature  became  normal,  the  child  failed  rapidly,  and 
there  was  so  much  emaciation  that  the  finger  and  thumb  could  easily  encircle  his  thigh. 

He  died  quietly  on  the  eighty-seventh  day  from  the  time  of  the  onset  of  the  disease. 

It  was  very  difficult,  indeed  impossible,  to  give  a  prognosis  in  this  case,  as  at 
times  it  seemed  as  though  he  would  recover,  and  then  the  temperature  would  rise 
again  and  the  unfavorable  symptoms  would  return. 

The  chart  shows  the  temperature  from  the  tenth  day  of  the  disease. 

TYPHOID  FEVER. 

Tj'phoid  fever  {enteric  fever,  typhoidal  ileo-colitis)  is  an  infectious  dis- 
ease produced  by  the  bacillus  of  Eberth.  The  conditions  and  manifesta- 
tions of  typhoid  fever  as  it  appears  in  the  foetus,  in  the  young  cliild,  and 
in  the  adult  differ  markedly. 

Typhoid  in  the  Foetus. — The  infection  of  the  foetus  may  take  place 
from  the  mother.  Abortion  occurs  in  from  fifty  to  seventy  per  cent.  It 
is  now  well  established  that  the  bacillus  of  t\^3hoid  can  pass  through  the 
placenta  from  the  mother  to  the  foetus,  and  it  seems  probable  that  this 
can  happen  when  the  placenta  is  intact.  In  most  cases  the  foetus  dies  in 
utero  ;  it  may,  however,  be  born  alive  but  suffering  from  the  infection. 
Again,  the  foetus  may  be  born  alive  and  healthy,  after  having  passed 
through  the  infection  in  utero.  Finally,  it  may  not  be  infected  at  all, 
although  the  mother  may  have  had  the  disease.  When  at  birth  the  foetus 
is  infected  it  rapidly  succumbs,  the  infection  showing  itself  in  the  form  of 
acute  cachexia  without  any  special  characteristics.  The  bacilli  in  these 
cases  are  most  commonly  found  in  the  liver,  spleen,  and  blood  ;  they  may 
also  be  found  in  the  intestine.  Marked  lesions  in  the  intestine  and  mes- 
enteric glands  are,  however,  never  found,  the  organs  usually  being  nor- 
mal. The  liver  and  spleen  are  sometimes  swollen,  and  may  show  minute 
hemorrhages.  An  explanation  of  these  lesions  is  found  in  the  entrance 
of  the  bacillus  through  the  umbilical  veins, — that  is,  the  septicaemia  is 
primary  and  not  secondaiy  to  an  enteritis.  These  cases  correspond  to 
those  of  typhoid  fever  in  adults  in  which  there  are  no  intestinal  lesions. 
There  may  also  be  an  infection  with  other  organisms  besides  the  typhoid 
bacillus,  especially  the  staphylococcus  aureus. 

Typhoid  in  Infancy  and  Early  Childhood. — The  pronounced  patho- 
logical lesions,  severe  symptoms,  and  great  virulence  in  type  which  are 
so  characteristic  of  typhoid  fever  of  later  years  are  so  rare  in  infancy  and 
early  life  that  the  following  description  will  be  confined  to  the  latter 
period. 

Etiology. — Typhoid  fever  is  exceedingly  rare  in  the  first  two  years  of 
life,  is  uncommon  under  three  years,  and  after  the  fifth  year  becomes 
more  common  as  the  child  grows  older.  Under  two  years  the  number 
of  cases  reported,  even  if  correct,  is  small.  In  fifty-five  cases  collated  in 
1895  by  Stowell,  the  diagnosis  in  twenty-eight  seemed  probable  ;  in  the 


440  PEDIATRICS. 

others  it  was  doubtful,  as  no  bacteriological  examination  was  made.  The 
youngest  authentic  case  of  typhoid  contracted  after  birth  is  that  reported 
by  Gerhardt  in  an  infant  which  presented  the  symptoms  when  twenty- 
five  days  old:  and  recovered  in  twelve  days.  In  StowelFs  series  sixteen 
confirmative  cases  have  been  reported.  Eight  of  these  cases  died.  In- 
fection may  take  place  in  any  way  by  which  the  germs  of  the  disease  can 
be  carried  from  one  individual  to  another.  The  germs  are  given  off 
from  the  discharges,  chiefly  the  faeces  and  the  urine.  The  individual  is 
infected  largely  through  the  gastro-enteric  tract,  and  the  most  usual  mode 
of  conveyance  into  the  body  is  by  infected  milk  or  water.  Direct  trans- 
mission by  the  hands  which  have  been  infected  from  the  surroundings  of 
the  patient,  especially  from  the  clothes  and  bed-linen,  is  possible. 

Pathological  Anatomy. — After  birth  in  the  earlier  periods  of  life  the 
pathological  lesions  are  less  definite  in  direct  ratio  to  the  age.  After  the 
second  or  third  years  the  lesions  are  constant  and  the  pathology  definite. 
Although  the  more  advanced  and  severe  lesions  of  typhoid  fever  may  occur 
in  the  early  as  well  as  in  the  later  years  of  life,  yet  its  characteristic  lesions 
in  young  subjects  are  found  in  the  milder  and  less  severe  pathological 
changes  of  the  disease.  These  consist  essentially  of  a  hyperplasia  of  the 
solitary  lymph-follicles  and  Peyer's  patches,  and  the  process,  instead  of 
going  on  to  ulceration,  usually  terminates  in  early  resolution  with  fatty 
degeneration  of  the  cells.  Hemorrhage  and  perforation  are  therefore  rare 
complications  in  the  typhoid  fever  of  early  life.  There  is,  however, 
nothing  distinctive  of  typhoid  fever  in  this  hyperplasia  of  the  lymph- 
follicles  in  children,  for  it  is  not  uncommon  to  find  this  condition  when 
death  has  occurred  from  other  diseases  of  the  intestine.  It  may  also  be 
present  in  such  diseases  as  measles,  diphtheria,  and  scarlet  fever.  Very 
marked  hyperplasia  of  the  lymph-follicles  may  be  produced  in  children 
by  irritating  substances  and  by  foreign  bodies,  not  only  food,  but  also 
drugs,  such  as  turpeth  mineral.  We  have,  in  fact,  seen,  at  the  post-mortem 
examination  of  a  child,  marked  enlargement  of  the  lymph-follicles  caused 
^'by  doses  of  turpeth  mineral  given  during  life  as  an  emetic. 

In  addition  to  the  lesions  in  the  intestine,  hyperplasia  of  the  mesen- 
teric glands,  granular  degeneration  of  the  liver  and  kidney,  and  granular 
or  fatty  degeneration  of  the  heart  may  be  found.  Parenchymatous 
changes  sometimes  occur  in  the  peripheral  nerves  and  degeneration  of 
the .  muscles.  The  pathological  conditions  in  typhoid  fever  in  the  early 
years  of  life  may  be  said  to  correspond  with  those  which  are  met  with 
in  the  aborted  forms  of  the  disease  in  later  life. 

The  specific  eftlorescence  of  typhoid  fever,  the  rose-spots,  have  ac- 
quired additional  importance  in  the  diagnosis  from  the  recent  bacterio- 
logical investigations  by  Neufeld  and  Curschman  in  Germany,  and  Rich- 
ardson in  this  country.  These  observers  have  demonstrated  the  presence 
of  the  typhoid  bacillus  in  the  rose-spots  in  a  very  large  proportion  of  the 
cases  examined.     In  Richardson's  series  the  diagnosis  was  made  by  this 


SPECIFIC   INFECTIOUS   DISEASES.  441 

method  on  an  average  of  six  days  before  the  appearance  of  the  Widal 
reaction. 

Incubation. — The  stage  of  incubation  in  typhoid  fever  may  last  from 
one  to  two  weeks ;  a  shorter  time,  however,  five  days,  and  a  longer  one, 
three  weeks,  have  been  observed. 

Symptoms. — The  prodromal  stage  is  usually  short,  young  subjects 
having  less  power  of  resistance  to  the  poison  than  adults,  in  whom  the 
prodromal  stage  is  often  prolonged.  The  onset  is  more  hkely  to  be  acute 
in  young  children,  and  nervous  symptoms,  especially  vomiting,  are  com- 
mon. 

The  duration  of  the  disease  is  generally  much  shorter  than  in  adults. 
This  short  duration  depends  largely  upon  the  mild  form  of  the  intestinal 
lesions  and  usually  indicates  that  marked  ulceration  has  not  taken  place. 
As  shown  by  the  figures  collected  by  Morse,  the  average  duration  of 
typhoid  fever  in  children  is  a  little  less  than  three  weeks,  the  younger  the 
child  the  shorter  the  duration,  and  the  proportion  of  cases  in  which  the 
duration  is  ten  days  or  less  is  twice  as  great  in  the  younger  children. 

As  a  rule,  the  temperature  is  moderate,  but  it  may  be  high,  as  in 
adults,  without,  however,  producing  as  severe  symptoms,  since  children  are 
generally  less  affected  than  adults  by  a  high  temperature.  When  the 
lesions  are  mild  the  temperature  is  not  apt  to  show  so  typical  a  course  as 
when  they  are  pronounced.  The  temperature  often  rises  rapidly  in  the 
beginning,  and  although  it  returns  to  the  normal  by  lysis,  it  does  not 
show  so  gradual  a  lysis  as  when  marked  lesions  have  occurred,  and  when 
other  symptoms  of  toxaemia  have  complicated  the  disease.  The  younger 
the  child  the  lower  the  range  of  the  temperature  and  the  sooner  is  the 
maximum  reached.  The  remittent  stage  occurring  in  adults  is  much  less 
in  children  and  the  defervescence  is  rapid. 

The  pulse  is  usually  accelerated,  but  is  low  in  comparison  with  the 
height  of  the  temperature  in  other  diseases,  and  is  not  so  apt  to  vary  from 
the  normal  in  strength  and  rapidity.     Hsemic  murmurs  are  not  uncommon. 

The  respirations  are  not  especially  increased  unless  some  complica- 
tion is  present.  Although  bronchial  catarrh  may  in  most  cases  be  patho- 
logically present  (Morse),  yet  clinically  its  importance  in  children  has  been 
rather  over-estimated.  In  certain  cases  in  young  children,  however,  it  is 
so  marked  as  to  be  liable  to  lead  to  the  error  of  considering  the  primary 
cause  of  pulmonary  origin  rather  than  intestinal. 

The  abdomen  may  be  distended  and  tympanitic,  but  this  symptom  is 
often  not  marked.  In  Morse's  statistics  distention  occurred  in  from  50  to 
70  per  cent,  of  all  cases.  It  is  more  common  in  older  children,  and  not 
infrequently  is  extreme.  Pain  and  tenderness  of  the  abdomen  are  rather 
unusual.  Vomiting,  especially  at  the  onset  of  the  disease,  is  often  met 
with,  but  is  rare  in  the  later  stages  of  the  disease.  Constipation,  especi- 
ally in  young  children  is  more  common  than  diarrhoea.  The  discharges 
are  not  so  characteristic  as  in  adults,  and  when  diarrhoea  is  present,  the 


442  PEDIATRICS. 

stools,  as  a  rule,  are  not  so  fi'L-queiit  or  so  laryu  in  amount.  All  the  fatal 
cases  noted  Jiv  Moi-se  had  diarrhoea.  Intestmal  hemorrhage  is  ven' 
unusual  under  ten  years  of  age,  and  is  fatal  in  about  half  the  cases. 
Perforation  is  exceedingly  rare.  Although  it  is  probable  that  in  all  cases 
of  tj-phoid  fever  there  is  some  enlargement  of  the  spleen,  it  is  often  un- 
possible  to  detect  this  change  by  palpation,  and  percussion  of  the  spleen 
in  young  children  is  well  known  to  be  verj'  misleading.  According  to 
ilorse's  figures  the  spleen  is  demonstrably  enlarged  in  90  per  cent,  of  all 
cases  of  typhoid  in  children,  and  the  older  the  cliild  the  greater  the 
enlargement.  The  return  of  the  spleen  to  its  normal  size  indicates  con- 
valescence and  recovery,  while  persistent  enlargement  shows  that  the  chs- 
ease  is  still  present. 

Epistaxis  occurs  more  rarely  than  in  adults. 

The  rose-colored  spots  appear  to  be  less  frequently  found  in  children 
than  in  adults.  Morse's  series  of  cases  showed  the  .spots  in  from  6U  to 
70  per  cent,  of  all  cases  in  children.  They  usually  appear  m  the  second 
week.  They  consist  of  smaU.  light-pmk  maculae,  usually  scattered,  cliiefly 
or  solely  on  the  abdomen,  and  disappearing  under  gentle  pressure  of  the 
fmger.  Other  varieties  of  efflorescences  are  seen  at  times,  but  are  un- 
common.    Herpes  labialis  occurs  in  some  cases. 

The  tongue  is  not  so  likely  to  be  dry  as  in  older  subjects,  and  although 
coated  it  soon  becomes  clean  at  the  tip  and  edges.  There  is  at  tmies  a 
slight  albuminuria  at  the  height  of  the  fever,  but  a  complicating  nephritis 
is  rare.  The  diazo-reaction  is  usually  present  in  the  urine  after  the  first 
week.  The  Widal  reaction  can  generally  be  obtained  in  the  second  week. 
The  infectious  nature  of  the  urine  should  always  be  borne  in  mind.  In  a 
considerable  proportion  of  cases  the  typhoid  bacilli  are  eliminated  in  tiie 
urine  and  often  cause  a  secondary  cystitis. 

The  more  severe  nervous  symptoms  so  pronounced  in  later  life  are 
not  prominent  in  early  childhood.  Headache  of  a  mild  type  is  common  ; 
severe  headache  is  very  uncommon.  Crying  out  at  night,  especially  in 
-young  children,  and  delirium  of  a  mild  type  are  not  uncommon.  Deep 
stupor  is  rare  ;  in  fact,  the  characteristic  of  typhoid  fever  in  young  children, 
as  Ave  have  seen  it,  is  apathy.  The  child  takes  the  nourishment  which  is 
given  to  it,  is  not  especially  restless,  and  usually  lies  in  a  half-somnolent 
condition.  As  the  disease  progresses  it  gradually  returns  to  a  more  natural 
mental  condition.  Convulsions  are  rare.  In  some  cases  cerebral  symp- 
toms, simulating  somewhat  those  of  meningitis,  arise,  and  are  frequently 
due  to  cerebral  congestion  or  to  toxic  action.  These  symptoms  are  more 
common  in  younger  children.  Hyperaesthesia,  changes  in  the  pupils,  re- 
traction of  the  head,  and  opisthotones  may  be  present,  closely  simulating 
meningitis.  True  meningitis  caused  by  the  bacillus  of  typhoid  is  rare,  but 
can  occur.  A  case  of  this  kind  with  the  bibliography  has  been  reported  by 
Wentworth  in  a  girl  four  years  of  age.  in  the  Transactions  of  the  American 
Pediatric  Society  of  1899.     Lumbar  puncture  in  tliis  case  showed  an  enor- 


SPECIFIC    INFECTIOUS    DISEASES.  443 

iiiuus  number  of  ty[>lioid  bacilli,  but  no  other  organisms  were  found.  The 
higlier  the  temperature  the  more  pronounced  are  tlie  nervous  symptoms. 

In  typhoid  the  leucocytes  are  usually  dunmished  in  number,  but 
there  is  a  proportionate  increase  in  the  lymphocytes.  In  the  early  stages 
the  erythrocytes  are  increased,  as  is  also  the  haemoglobin.  In  the  later 
stages  a  condition  of  secondary  anaemia  may  occur,  producing  a  diminu- 
tion of  the  red  blood-corpuscles  and  haemoglobin. 

Complications  and  Sequelae. — Pulmonary  complications,  with  the  ex- 
ception of  bronchitis,  are  rare.  Neuritis  is  not  an  uncommon  complica- 
tion. Aphasia  occurs  rather  more  frequently  in  children  than  in  adults. 
In  rare  cases  it  may  be  due  to  some  organic  cause,  such  as  embolism, 
but,  as  a  rule,  there  is  no  demonstrable  lesion.  According  to  Morse's 
statistics,  in  most  cases  it  occurs  where  the  typhoid  had  been  extreme, 
accompanied  by  other  marked  nervous  manifestations,  and  coming  on 
during  convalescence  while  the  temperature  was  falling.  The  intelligence 
is  retained,  and  there  is  rarely  any  other  paralysis.  Recovery  was  the 
rule,  and  the  average  duration  was  three  weeks.  Even  when  partial 
paralysis  has  accompanied  the  aphasia,  entire  recovery  may  take  place. 
Chorea  and  parotitis  are  not  verj^  uncommon,  and  otitis  media  is  not  in- 
frequent. Relapses  are  about  as  frequent  as  in  adults.  According  to 
Morse's  figures,  the  number  of  days  of  fever  in  thirty  relapses  was  fifteen, 
the  shortest  seven  days,  and  the  longest  twenty-nine  days.  His  number 
of  days  of  apyrexia  before  the  relapse  varied  from  none  to  nineteen  days. 
They  follow  about  the  same  course  as  the  normal  attack,  but,  as  a  rule, 
are  of  shorter  duration,  the  symptoms  being  less  severe. 

Diagnosis. —  Widal  Reaction. — During  the  first  few  days  typhoid  fever 
may  often  be  mistaken  for  various  forms  of  febrile  gastro-enteric  disease. 
The  most  important  means  of  diagnosis  is  by  the  Widal  serum-reaction. 
By  this  is  meant  the  clumping  and  loss  of  motility  of  the  typhoid  bacilli 
when  the  serum  of  a  patient  sick  with  typhoid  fever  is  added  to  a  bouillon 
culture  of  typhoid  bacilli.  A  freshly  prepared  bouillon  culture  not  more 
than  twenty-four  hours  old  and  grown  at  room  temperature  should  be 
used.  Not  less  than  ten  parts  of  the  culture  should  be  added  to  one  of 
the  serum.  No  reaction  occurring  after  half  an  hour  should  be  accepted. 
This  reaction  is  usually  not  present  until  the  beginning  of  the  second 
week,  but  may  last  for  weeks  or  months  after  the  recovery.  If,  there- 
fore, a  reaction  is  positive,  it  is  necessary,  in  order  to  be  accurate,  to 
exclude  a  recent  typhoid.  While  this  is  the  most  important  method  of 
diagnosis  in  typhoid  fever,  it  is  not  absolute,  as  the  reaction  is  not  always 
present  in  typhoid,  and  may  rarely  occur  in  other  diseases.  The  error  is 
about  five  per  cent,  in  either  direction. 

Infants  born  alive  or  dead  of  mothers  who  have  typhoid  may  or 
may  not  show  the  serum-reaction.  The  reaction  may  be  transmitted  to 
a  healthy  infant  from  the  breast-milk.  The  reaction  is  less  intense  in 
the  mother's  milk  than  in  her  blood,  and  less  in  the  infant's  blood  than 


444  PEDIATRICS. 

in  the  milk.  The  agglutinating  principle  may  not  bo  transmitted  to  the 
infant  through  the  milk.  The  transmission  probably  depends  largely  on 
the  strength  of  the  agglutinating  power  in  the  blood  and  milk.  The  re- 
action disappears  in  a  few  days  after  the  cessation  of  nursing. 

Diazo-Readion. — Not  so  much  value  as  formerly  is  attributed  to  the 
diazo-reaction.  because  it  is  also  found  in  acute  tuberculosis,  septicaemia, 
measles,  pneumonia,  and  probably  also  in  many  of  the  acute  febrile 
diseases.  It  does  not  develop,  however,  in  acute  tuberculosis  until  after 
the  tliird  week  of  the  disease  ;  whereas  in  typhoid,  if  it  is  to  appear  at 
all.  it  is  usually  obtained  by  the  end  of  the  first  or  in  the  second  week. 

White  Blood  Count. — Another  important  aid  in  the  differential  diag- 
nosis of  tj^hoid  may  be  obtained  by  the  white  blood  count.  The  absence 
of  leucocytosis  is  the  characteristic  point  of  the  blood  in  typhoid,  and  serves 
to  exclude  many  other  diseases  in  wliich  leucocjiosis  is  present.  It  is 
always  to  be  borne  in  mind,  however,  that  a  high  white  blood  count  may 
be  fomid  m  a  case  of  typhoid  which  is  complicated  by  some  disease 
which  is  accompanied  by  a  leucoc^iosis.  Typhoid  fever,  therefore,  is  not 
to  be  excluded  because  of  a  leucocytosis,  unless  complicating  conditions 
can  positively  be  proved  to  be  absent. 

Typhoid  Bacilli  in  the  Bose-Sjyots. — The  detection  of  the  typhoid  bacilli 
in  the  rose-spots  is  a  point  in  the  differential  diagnosis  which  may  be 
attempted  in  all  doubtful  cases :  theu'  presence  makes  the  diagnosis 
certain.  In  making  the  differential  diagnosis,  therefore,  on  a  doiAtful 
case  of  typhoid,  the  most  important  evidence  is  to  be  found  in  the  results 
of  the  Widal  and  diazo-reactions.  the  white  blood  count,  and  the  rose- 
spots.  The  onset  of  the  disease,  the  course  of  the  temperature,  and 
the  whole  series  of  abdommal  symptoms  must  be  considered  as  supple- 
mentary and  confirmaton^  evidence. 

The  diseases  Avhich  are  most  likely  to  simulate  typhoid  fever  and 
render  the  diagnosis  difficult  are  as  follows  : 

The  Exanthemata  and  Pneumonia. — A  number  of  acute  diseases,  such 
as  the  exanthemata  and  pneumonia  may  simulate  in  then-  prodromal 
stage  those  cases  of  t^-phoid  fever  which  begin  with  violent  symptoms.  In 
pneumonia  and  scarlet  fever  there  is  leucocTtiosis,  in  typhoid  fever  there 
is  none  ;  moreover,  m  the  former  diseases  there  is  no  Widal  reaction  and 
no  diazo  in  scarlet  fever.  In  measles,  however,  there  is  no  leucocytosis, 
while  the  diazo-reaction  may  be  present.  After  the  prodromal  symptoms 
have  passed,  the  distinctive  efflorescences  of  measles  and  scarlet  fever  and 
the  course  of  the  disease  Avill  serve  to  differentiate  them,  while  the  tem- 
perature curve  and  physical  signs  will  determine  the  presence  of  pneumonia. 
Acute  Ileo-Colitis. — Tj-phoid  fever  and  ileo-colitis  may  sometimes  simu- 
late each  other.  The  intestinal  symptoms  of  typhoid  fever  m  young  chil- 
dren, however,  correspond  so  closely  to  the  severity  of  the  local  lesions 
that  it  is  rare  m  the  early  days  of  the  disease  to  meet  with  the  severe 
intestinal  symptoms  so  common  in  ileo-colitis  ;  those  of  typhoid,  as  a  rule. 


SPECIFIC   INFECTIOUS   DISEASES.  445 

being  much  milder.  Later  in  the  disease  the  splenic  enlargement,  efflores- 
cence, and  tympanites  of  typhoid  are  not  found  in  ileo-colitis.  The  blood 
of  typhoid  does  not  show  leucocytosis,  while  this  is  usually  present  in  other 
forms  of  gastro-enteric  infection.  While  the  Widal  and  diazo-reactions 
are  generally  present  in  typhoid,  the  former  never  occurs,  and  the  latter 
rarely,  in  gastro-enteric  disease.  The  temperature  curve  also,  after  the 
early  days  of  the  disease,  is  of  considerable  aid  in  diagnosis. 

Tubercular  and  Epidemic  Cerebro-Spinal  Meningitis. — The  vomiting 
which  occurs  in  the  prodromal  stage  of  typhoid  fever  may,  in  connection 
with  the  child's  apathy,  simulate  the  early  stages  of  tubercular  meningitis, 
but  the  higher  temperature,  enlarged  spleen,  and  distended  abdomen  of 
typhoid,  and  the  absence  of  the  irregular  respirations,  slow,  intermittent 
pulse,  and  retracted  abdomen  of  meningitis  serve  to  differentiate  the  two 
diseases.  In  tubercular  meningitis  the  evidence  given  by  lumbar  punc- 
ture and  the  absence  of  the  Widal  reaction  separate  the  disease  from 
typhoid.  In  both  diseases  the  diazo-reaction  may  be  present,  and  leucocy- 
tosis is  absent  in  both.  In  rare  cases  the  bacilli  of  typhoid,  as  already 
stated,  may  be  the  cause  of  a  meningitis  and  the  disease  be  diagnosticated 
during  life  by  lumbar  puncture.  In  cerebro-spinal  meningitis  the  diplo- 
coccus  intracellularis,  obtained  by  lumbar  puncture,  is  not  found  in 
typhoid ;  there  is  marked  leucocytosis,  and  while  the  Widal  reaction  is 
always  absent,  the  diazo  may  be  present. 

Acute  Miliary  Tuberculosis. — The  most  difficult  of  all  the  diseases  to 
differentiate  from  typhoid  is  acute  miliary  tuberculosis.  The  absence  of 
leucocytosis  and  the  possible  presence  of  the  diazo-reaction  occurs  in 
both  diseases,  but  the  Widal  reaction  is  not  present  in  tuberculosis,  and 
thus  becomes  invaluable  in  diagnosis.  Until  other  evidence  of  tubercular 
processes  appear  locally,  as  in  the  lungs,  it  is  often  only  by  the  persist- 
ence of  the  fever  and  prostration  beyond  the  usual  period  of  typhoid  that 
tuberculosis  can  be  distinguished  from  the  prostration  and  continued  fever 
of  typhoid.  It  is  especially  in  the  typhoidal  type  of  acute  miliary  tuber- 
culosis that  the  resemblance  of  the  two  diseases  is  closest,  and  when  in 
typhoid  the  rose-colored  spots  do  not  appear  and  the  Widal  reaction  is 
negative,  the  delirium,  distended  abdomen,  enlarged  spleen,  and  even 
the  irregular  temperature  at  times  common  to  both  diseases,  may  make 
the  resemblance  so  close  that  the  diagnosis  cannot  be  made  until  the 
post-mortem  examination. 

Malaria. — The  differential  diagnosis  between  typhoid  fever  and  mala- 
ria is,  at  times,  especially  in  children  under  two  years  of  age,  very  diffi- 
cult and  perhaps  impossible  until  the  blood  has  been  examined.  The 
difference  in  the  temperature  curve,  the  presence  of  the  Plasmodium,  the 
marked  effect  on  the  symptoms  by  the  use  of  quinine,  and  the  absence 
of  the  Widal  and  diazo-reactions  in  malaria,  are  of  much  value  in  the  diag- 
nosis from  typhoid.     Leucocytosis  is  absent  in  both  malaria  and  typhoid. 

Epidemic  Influenza, — Epidemic  influenza    may  in  its  onset  simulate 


446  PEDiArr.u's. 

typhoid  Ibver,  but  tlie  period  of  doubt  is  very  slioii.  Tlic  presence  of 
Pfeiffer's  bacillus,  if  it  can  be  found  in  the  sputum  or  nasal  discharge,  is 
of  importance,  but  the  absence  of  the  Widal  and  diazo-reactions  are  not 
of  so  much  importance,  as  the  disease  has  either  run  its  course  or  de- 
clared itself  by  its  temperature  and  irregular  groups  of  symptoms  before 
the  time  for  obtaining  these  reactions  has  arrived.  It  is,  therefore,  impos- 
sible in  the  early  days  of  the  disease  to  make  a  positive  diagnosis,  and  in 
some  cases  we  are  left  in  doubt  as  to  the  diagnosis  at  even  a  later  period, 
when  the  symptoms  of  enlarged  spleen,  rose-colored  spots,  and  tympanitic 
abdomen  of  typhoid  are  not  present  as  a  group.  Tlie  white  blood  count 
is  of  little  service,  as  it  is  generally  normal  in  epidemic  influenza. 

Prognosis. — The  prognosis  of  typhoid  fever  in  early  childhood  is  good. 
Statistics  show  that  the  disease  is  much  less  fatal  in  children  than  in  adults, 
and  that  the  mortality  increases  directly  with  the  age.  The  complications, 
whether  arising  from  local  disturbance  of  the  intestine  or  from  cardiac  and 
pulmonary  disease,  are  rare  in  comparison  with  those  met  with  in  later 
life.  The  disease,  however,  varies  very  much  in  its  severity  in  different 
epidemics  and  in  different  stages,  and  a  child  may  have  a  severe  type  of 
typhoid  fever  and  die  from  it. 

Treatment. — The  treatment  of  the  mild  form  and  that  most  commonly 
met  with  in  young  children  is  exceedingly  simple.  The  child  should  be 
kept  perfectly  cfuiet  in  bed  as  long  as  the  temperature  is  raised,  and  for 
three  or  four  days  after  it  has  become  normal.  Although  in  adults  quite 
a  varied  diet  can  be  given,  in  young  children  milk  in  some  form  through- 
out the  whole  course  of  the  disease  is  indicated.  There  are  no  drugs 
which  will  either  abort  or  cure  the  disease.  In  the  cases  which  begin 
acutely  with  vomiting,  food  should  be  withheld  for  some  hours,  and  the 
prodromal  symptoms  treated  symptomatically,  as  the  same  symptoms 
would  be  in  the  beginning  of  a  number  of  acute  febrile  diseases.  After 
the  acute  symptoms  have  passed,  alkaline  milk  should  be  given  with 
low  percentages  of  fat,  sugar,  and  proteids  at  first,  and  these  elements 
-  should  be  gradually  increased  in  their  percentages,  and  varied  in  their  com- 
binations to  suit  the  especial  age  and  digestion.  It  is  usually  better  to 
heat  the  milk  to  68.3°  C.  (155°  F.)  and  to  add  lime-water,  five  per  cent. 
Where  the  stomach  is  at  all  irritable  it  is  often  well  to  peptonize  the  milk 
for  a  time.  It  is  seldom  that  the  temperature  is  so  high  as  to  call  for  any- 
thing beyond  bathing,  and,  as  a  rule,  antipyretics  should  be  avoided.  As 
a  hygienic  measure  the  child  should  be  bathed  twice  daily  with  water 
heated  to  32°  C.  (90°  F.).  If  the  temperature  rises  to  39.4°  or  40°  C. 
(103°  or  104°  F.)  a  reduction  by  artificial  means  is  not  necessarily  indi- 
cated, but  we  should  be  guided  by  the  general  condition  of  the  child. 
According  to  our  experience  at  the  Children's  Hospital,  a  large  number 
of  children  of  all  ages  pass  through  an  attack  of  typhoid  without  any 
necessity  arising  for  the  reduction  of  the  temperature  by  baths  or  sponging. 
The  older  the  child  the  more  likely  is  the  bath  to  be  indicated.     Much 


SPECIFIC    IXFECTIOrS    DISEASES.  447 

■pulmonary  or  cardiac  weakness  contra-indicates  the  bath.  Tlie  child  can 
be  either  sponged  for  five  or  ten  minutes,  or  wrapped  in  a  thin  blanket 
and  placed  in  the  bath,  while  the  body  and  limbs  are  actively  rubbed. 
Where  there  is  delirium  and  great  restlessness,  with  a  temperature  of 
40.5°  or  41.1°  C.  (105°  or  106°  F.)  baths  should  be  given  every  three  or 
four  hours,  but  with  caution,  as  children  do  not  react  so  well  as  adults. 
A  stimulant,  such  as  a  few  drops  of  brandy,  should  be  given  at  the  time 
of  the  sponging  or  bath. 

The  urine  should  be  closely  watched  for  evidence  of  typhoid  bacilluria. 
which  is  usually  shown  by  slight  cloudiness  when  it  is  freshly  passed. 
Cultures  may  be  made  and  the  bacilli  demonstrated.  They  cjuickly  dis- 
appear upon  the  administration  of  urotropine  or  cystogen  in  0.3  gramme 
(5  grains)  doses  three  times  a  day. 

Technique  of  the  Bath  in  Typhoid  Fever. — A  very  convenient  method 
of  administering  the  bath  in  typhoid  fever,  or  in  any  other  condition  in 
which  the  treatment  is  indicated,  is  as  follows : 

A  large  rubber  sheet  is  placed  under  the  child  on  the  bed,  and  the 
sides  and  ends  are  bolstered  up  by  rollers  or  bedding,  making,  if  properly 
arranged,  a  shallow  but  sufficiently  large  tub  without  the  inconvenience 
of  moving  the  child.  A  towel  or  blanket  may  be  placed  under  the  child 
if  it  is  made  uncomfortable  by  lying  directly  on  the  rubber  sheet.  The 
Avater  is  brought  in  a  foot-tulD  to  the  side  of  the  bed,  and  its  temperature 
regulated  according  to  the  indications.  A  wet  towel  or  sponge  is  placed 
on  the  head ;  the  water  is  then  squeezed  from  a  sponge  on  to  the  naked 
body  with  one  hand,  and  brisk  friction  is  apphed  with  the  other.  The 
chest,  abdomen,  arms,  and  legs  should  be  taken  in  rapid  succession.  It  is 
especially  to  be  noted  that  it  is  the  combination  of  friction  with  water 
which  accomplishes  the  best  result  in  reducing  the  temperature  and  at 
the  same  time  stimulating  the  peripheral  circulation.  The  child  is  then 
turned  on  its  side,  and  the  back  is  bathed  and  rubbed  in  the  same 
manner.  The  duration  of  the  bath  should  vary  from  five  to  fifteen  min- 
utes, according  to  the  height  of  the  temperature  and  the  manner  in  which 
the  child  reacts.  The  temperature  of  the  water  should  vary  from  37.7° 
C.  (100°  F.)  to  23.8°  C.  (75°  F.),  according  to  the  age  of  the  child,  the 
height  of  the  fever,  the  number  of  degrees  of  reduction  in  the  tempera- 
ture obtained,  and  the  manner  in  which  the  child  reacts.  A  drop  in  the 
temperature  of  one  to  one  and  a  half  degrees  centigrade  is  the  object 
especially  to  be  attained.  The  temperature  is  best  taken  one-half  hour 
after  the  bath.  Drops  of  two  and  three  degrees  centigrade  are  not  de- 
sirable. If  the  bath  is  well  given  by  an  experienced  nurse,  a  good  reaction 
should  usually  be  obtained.  Slight  blueness  of  the  lips  and  finger-nails, 
cold  hands  and  feet,  and  chilly  sensations  should  be  watclied  for  and  treated 
by  a  dose  of  brandy  and  water,  an  extra  blanket,  and  heaters  in  the  bed. 
jMassage  of  the  extremities  under  the  blankets  may  be  all  that  is  necessarj'. 

Care  of  the  Mouth  and  Skin. — The  mouth  should  be  gently  but  thor- 


448  PEDIATRICS. 

oughly  cleansed  with  a  two  per  cent,  solution  of  boracic  acid  in  distilled 
water  at  least  three  times  daily.  The  greatest  care  should  be  taken  to 
prevent  irritation  of  the  skin  by  bathing  the  recumbent  parts  with  alcohol 
and  water. 

Diarrhoea,  unless  profuse  and  exhausting  or  very  frequent,  such  as 
more  than  three  or  four  in  twenty-four  hours,  should  not  be  checked. 
To  control  peristalsis  bismuth  and  small  doses  of  opium  are  indicated. 

Constipation. — There  is  usually  more  difficulty  with  constipation  than 
w4th  diarrhoea.  Enemata  and  suppositories  are  indicated  rather  than  laxa- 
tives, which  should  be  only  used  in  extreme  cases,  and  necessarily  sparingly 
and  in  a  mild  form,  such  as  the  milk  of  magnesia  3.75  to  6.50  c.c.  (1  to 
2  drachms),  with  an  occasional  small  dose  of  castor  oil.  The  discharges 
should  be  disinfected  at  once  with  a  1  to  20  solution  of  carbolic  acid. 
All  the  clothing  should  be  soaked  in  carbolic  acid,  twenty  per  cent.,  for 
six  hours,  and  then  boiled  for  one  hour. 

Headache,  Restlessness,  Sleeplessness. — These  nervous  symptoms  are 
best  treated  by  bathing.  If  a  sedative  is  desired,  0.12  to  0.3  gramme 
(2  to  5  grains)  doses  of  trional  are  safe  and  efficient.  Bromide  of  soda 
may  be  given  alone  or  in  combination  with  trional. 

Tympanites  should  be  treated  with  hot  cloths  applied  to  the  abdomen, 
or  by  turpentine  stupes  made  in  the  following  manner :  one  part  of 
spirits  of  turpentine  is  mixed  with  six  parts  of  sweet  oil,  and  the  mixture 
is  then  rubbed  gently  but  thoroughly  on  the  abdomen.  A  thick  piece  of 
flannel  is  then  dipped  in  hot  water,  wrung  out,  and  when  sufficiently 
cool  applied  to  the  abdomen,  covered  with  oiled  paper,  and  kept  in 
place  by  a  thick  swathe.  If  these  precautions  are  taken,  irritation  of  the 
skin  will  rarely  be  caused,  and  the  treatment  is  very  efficacious.  Gentle 
irrigation,  of  the  colon  with  some  saline  solution,  such  as  a  two  per  cent, 
borate  of  soda  or  a  three  per  cent,  boracic  acid  solution,  may  be  tried.  In 
extreme  cases  the  rectal  tube  may  be  used  with  caution. 

Hemorrhages  and  perforations  should  be  treated  as  in  the  older  cases, 
the  former  with  absolute  rest,  with  hypodermic  injections  of  ergotin  0.06 
c.c.  (1  grain),  and  sometimes  of  morphine  and  cold  to  the  abdomen,  and 
the  latter  with  hypodermic  injections  of  moriDhine  0.001  to  0.003  c.c.  (g-V 
to  2V  grain). 

Laparotomy  for  perforation  in  typhoid  has  not  been  attended  by  bril- 
liant results,  but  in  certain  cases  may  be  deemed  advisable.  The  same 
care  should  be  exercised  during  the  convalescence  of  the  child  as  in  the 
advanced  convalescence  of  the  adult. 

Stimulants  are  not  called  for,  as  a  rule,  in  the  early  stages  of  the  dis- 
ease. When  used  they  are  best  administered  in  the  form  of  brandy  or 
whiskey.  They  are  contra-indicated  in  the  stage  of  toxEemia  represented 
by  marked  excitement,  active  delirium,  cerebral  congestion  with  delusions 
and  great  restlessness,  and  a  strong,  full  pulse.  On  the  other  hand,  when 
the  pulse  is  small  and  weak,  when  the  mental  condition  is  expressed  by 


SPECIFIC    IXFECTIOUS   DISEASES. 


449 


depression,  low  muttering,  delirium,  and  a  general  condition  of  nervous 
exhaustion,  ilie  use  of  stimulants,  especially  in  the  form  of  alcohol,  is  dis- 
tinctly indicated,  and  is  highly  beneficial.  For  an  infant  of  one  year  the 
amount  of  brandy  or  whiskey  in  twenty-four  hours  should  vary  from  15 
c.  c.  (I  ounce)  to  30  c.  c.  (1  ounce),  but  should  never  exceed  60  c.  c.  (2 
ounces).  In  children  of  four  years  these  doses  may  be  doubled  in  corre- 
sponding conditions.  In  all  cases  the  stimulant  should  be  well  diluted. 
If  in  a  hemorrhage  from  the  bowels  a  stimulant  must  be  given,  it  should 
be  administered  in  small  doses  and  in  combination  with  opium.  A  table 
giving  the  doses  of  other  cardiac  stimulants  will  be  found  on  page  464. 
The  following  case,  Fig.  110.  was  under  our  care  at  the  City  Hospital : 

A  boy,  five  years  old,  was  taken  sick,  with  general  malaise  and  fever  five  days 
before  entering  the  hospital.  There  had  been  no  other  symptoms,  such  as  epistaxis  or 
vomiting.  On  entering  the  hospital,  an  examination  showed  the  tongue  to  have  a 
thick  brow-nish  coat  in  the  centre  and  a  thin  coat  on  the  tip  and  edges.  The  child  was 
in  an  apathetic  condition.  The  pulse  was  rapid  and  regular.  Nothing  abnormal  w-as 
found  in  the  thorax.  The  abdomen  was  distended  and  tympanitic,  and  showed  one 
rose-colored  spot.  The  spleen  could  be  easily  felt  2.5  cm.  (1  inch)  below  the  border 
of  the   ribs,  and  on  percussion  the  dulness  reached  as  high  as  the  seventh  rib  in  the 


Fig.   110. 


.^" 


Typhoid  fever.    Male,  5  years  old. 


axillary  line.  The  enlargement  of  the  spleen  and  the  lower  border  of  the  ribs  are  marked 
in  black  in  Fig.  111.  The  upper  border  of  the  splenic  dulness  is  marked  by  a  broken 
line,  and  the  figure  7  marks  the  seventh  rib.  The  blood  showed  no  leucocytosis. 
The  pupils  reacted  equally  to  light.  The  expression  of  the  child's  face  was  apathetic, 
and  he  took  very  little  notice  of  anything.  An  examination  of  the  urine  showed  the 
color  to  be  normal,  the  reaction  neutral,  the  specific  gravity  1026,  and  that  there  was 
a  slight  trace  of  albumin.  The  sediment  showed  occasional  hyaline  and  fine  granular 
and  fibrinous  casts.     A  Widal  reaction  was  not  obtained. 

On  the  third  day  after  entering  the  hospital,  the  eighth  day  of  the  disease,  the 
child  became  very  stupid  and  sometimes  delirious.     There  was  a  slight  cough.      On 

29 


450 


PEDIATRICS. 


the  twelfth  day  of  the  disease  the  child  cried  out  at  times,  ani  was  delirious.  The 
skin  was  dry  and  hot.  There  were  no  more  rose-colored  spots.  There  seemed  to  be 
slight  tenderness  in  the  lower  iliac  fossa,  but  there  was  no  gurgling.  On  the  fifteenth 
day  of  the  disease  the  temperature  began  to  fall  by  lysis,  and  the  child  began  to  be 
fretful.  On  the  eighteenth  day  the  temperature  became  normal.  By  the  twenty-first 
day  the  child  seemed  bright,  and  was  playing  with  its  toys.  The  pulse  was  stronger. 
One  week  later  it  was  sitting  up  in  bed,  and  had  a  strong  pulse  and  a  good  appetite. 
A  few  days  afterwards  it  was  up  and  about  the  ward,  perfectly  well.  •  The  following 
chart  shows  the  temperature,  pulse,  and  respiration  from  the  fifth  day  of  the  child's 
illness  until  convalescence  was  established  on  the  the  twenty-fifth  day. 

The  following  notes  and  plate  (Fig.  Ill)  were  given  to  us  by  Dr.  S.  S.  Adams,  of 
Washington,  and  occurred  in  an  infant  two  years  old.  In  this  case  the  irregularity  of 
the  temperature  curve  and  the  prominent  symptoms  of  cerebro-spinal  irritation  rendered 
the  diagnosis  so  obscure  that  typhoid  fever  was  not  suspected  until  a  few  days  before  death. 
The  post-mortem  examination  showed  marked  congestion  of  the  entire  brain,  chiefly  on 
the  right  side.     The  left  hemisphere  ■was  covered  with  a  glue-like  substance  which  filled 


CHAKT    12. 

DAYS  OF  DISEASE                                                   I 

F.     5     6     r    8     5   10  11  12  13  14  1 

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Typhoid  fever.    Male,  5  years  old. 


the  sulci  and  was  especially  abundant  around  to  Sylvian  fissure.  The  heart  was  normal. 
The  lungs  showed  marked  hypostatic  congetion  The  liver  was  normal.  The  gall-, 
bladder  was  empty  and  pale.  The  spleen  was  enlarged.  The  kidneys  were  normal. 
The  stomach  was  congested.  The  mesenteries  glands  were  enlarged  and  soft.  The  in- 
testines contained  a  quantity  of  yellowish  w^atery  faces.  The  lesions  w^ere  in  the  ileo- 
colic portion  of  the  intestine.  There  was  thickening  and  ulceration  of  Peyer's  patches, 
and  to  a  less  extent  of  the  solitary  follicles. 

Swelling  of  Peyer's  patches  and  of  the  solitary  follicles  is  not  dis- 
tinctive of  typhoid  fever,  as  this  condition  frequently  occurs  from  irrita- 
tions of  various  kinds.  Fig.  112  represents  a  section  taken  from  the 
intestine  of  a  child.     Cultures  showed  no  typhoid  bacilli. 


Fiu. 111. 


Typhoidal  ileocolitis.  slioT.^-ing  ulcers  of  colon.    Female,  2  years  old. 
U.  S.  Armv  Medical  Museum. 


Fig.  112. 


Enlarged  Peyer's  patches  closely  svmulating  the  lesions  of  typhoidal  ileo-eolitis.    Muc.  Mem.,  mucous 
membrane  ;  FoL,  enlarged  follicles;  Mus.,  muscle. 


SPECIFIC  INFECTIOUS  DISEASES.  45 1 

TYPHUS  FEVER. 

Typhus  fever  is  an  acute  infectious  disease,  the  cause  of  which  has 
not  yet  been  determined.  In  America  typhus  fever  is  an  exceedingly  rare 
disease,  but  in  England  it  is  well  known  to  occur  in  children  as  well  as  in 
adults.  According  to  Collie,  out  of  711  admissions  to  the  Hunnerton 
Fever  Hospital  during  a  period  from  1871  to  1880,  24  were  under  five 
years  of  age,  54  from  five  to  nine  years,  and  113  were  from  ten  to  four- 
teen years.  Buchanan  has  shown  that  typhus  fever  in  early  life  is  very 
mild,  but  that  children  are  just  as  susceptible  as  adults. 

Symptoms. — The  onset  is  acute.  According  to  Asliby  and  Wright  the 
attack  begins  with  headache,  pams  in  the  limbs,  drowsiness,  sometimes 
vomiting,  and  rarely  diarrhoea.  The  constitutional  symptoms  are  of  a 
severe  type.  The  tongue  is  dry  and  coated,  there  are  sordes  on  the 
teeth,  and  the  gums  bleed  easily.  On  the  fourth  or  fifth  day  the  skin 
assumes  a  dusky,  congested  appearance,  with  an  indistinct  mottling. 
Sometmies  there  are  rose-colored  spots  or  maculte,  larger  than  those 
seen  in  typhoid,  appearing  first,  according  to  Collie,  on  the  upper  front 
portions  of  the  chest,  on  the  wrists,  on  the  backs  of  the  hands,  and  in  the 
epigastrium. 

The  temperature  is  usually  continuously  high,  varymg  from  39.4°  to 
40°  C.  (103°  to  104°  F.),  and  the  pulse  120  to  130,  and  rather  weak.  The 
temperature  usually  becomes  normal  by  about  the  eighth  or  tenth  day. 

Prognosis. — The  prognosis  is  usually  good.  Out  of  191  children 
under  fourteen  years  of  age  only  two  deaths  took  place,  while  the  total 
mortality  for  all  ages  was  20  per  cent. 

Treatment. — Especial  attention  should  be  paid  to  the  hygienic  sur- 
roundings, such  as  fresh  air,  sunlight,  and  warmth.  Daily  sponging  and 
the  free  use  of  stimulants  are  indicated.  The  diet  should  be  milk  and 
broths  until  convalescence  is  well  established. 

DIPHTHERIA. 

Diphtheria  is  an  acute,  highly  infectious  disease,  due  to  the  Klebs- 
Loeffler  bacillus.  It  is  primarily  a  local  affection,  the  constitutional  symp- 
toms being  due  not  to  the  presence  of  the  organism  in  the  blood,  but  to 
the  absorption  of  the  toxins  caused  by  the  growth  of  the  bacillus. 
Although  the  term  diphtheria,  derived  from  the  Greek  word  occpOspa, 
implies  a  membrane,  and  the  disease  is  usually  accompanied  by  a  pseudo- 
membrane,  yet  it  must  be  understood  that  the  disease  is  not  diphtheria 
unless  the  specific  germ  is  present.  This  germ  may  act  idth  different 
degrees  of  intensity,  and  thus  cause  inflammation  varying  from  a  slight 
catarrhal  condition  to  the  most  serious  membranous  one.  In  like  man- 
ner, according  as  the  form  is  mild  or  severe,  there  may  be  very  slight 
constitutional  symptoms  or  exceedingly  serious  ones.  There  is  probably 
a  concurrent  infection  with  pyogenic  cocci.     These  organisms  produce  the 


452  PEDIATRICS. 

secondary  inflammations  occurring  in  tlie  disease,  and  also  by  their  toxins 
give  rise  to  additional  constitutional  symptoms. 

Etiology. — The  Klebs-Loetfler  bacillus  was  first  described  by  Klebs 
in  1883,  and  later  was  more  fully  identified  by  Loeffler  in  1884.  Its 
most  striking  features,  morphologically,  are  its  variation  in  form  and  the 
irregularity  in  its  manner  of  staining.  It  does  not  form  spores.  AVelch 
and  Abbott  have  shown  that  in  fluids  it  may  be  killed  by  an  exposure  of 
ten  minutes  to  a  temperature  of  58°  C.  (136.4°  F.).  Under  favorable 
conditions  it  may  remain  alive  for  weeks,  or  even  months,  in  fragments 
of  dried  membrane. 

The  pathogenic  cocci  most  frequently  found  in  the  concurrent  infec- 
tions are  the  streptococcus  pyogenes  alone,  or  associated  with  the  staphy- 
lococcus pyogenes  aureus,  the  former  being  the  most  important  in  its 
action.  There  is  no  true  diphtheria  where  the  Klebs-Loeffler  bacillus  is 
not  present,  but  its  presence  in  a  healthy  throat  does  not  constitute  the 
disease  diphtheria,  although  the  individual  may  be  the  source  of  infection 
to  others.  It  is  undoubtedly  a  contagious  disease  of  local  origin,  and  it 
does  not  originate  spontaneously.  The  contagium  of  diphtheria  is  con- 
tained chiefly  in  the  secretions  of  the  throat  and  nose,  and  is  communi- 
cated usually  by  direct  or  indirect  contact,  and  not,  as  a  rule,  by  the  air. 
The  area  of  infection  is  not  so  great  as  in  scarlet  fever.  It  is  not  found 
in  the  urine  and  fasces.  Sewer  gas  and  confined  impure  matter  of  any 
kind  may  act  by  weakening  the  resistance  of  the  body  to  the  action  of  the 
bacilli,  or,  by  producing  a  benign  lesion  in  the  throat,  may  otfer  a  suit- 
able nidus  for  the  invasion  of  the  bacillus.  It  is  now,  however,  con- 
ceded that  imperfect  drainage  and  unsanitary  conditions  should  not  be 
considered  important  factors  in  increasing  the  frequency  of  the  disease. 
Animals,  such  as  cows,  cats,  dogs,  and  pigeons,  may  have  diphtheria,  and 
be  a  source  of  infection  to  those  brought  in  contact  with  them.  There  is 
no  positive  evidence  that  the  milk  of  cows  affected  by  diphtheria  contains 
the  germs  of  the  disease,  but  the  probability  is  that  the  milk  in  some  of 
these  cases  may  be  contaminated  by  the  hands  of  the  milkers.  The  cases 
in  which  the  pharynx  and  nose  are  affected  are  the  most  contagious  on 
account  of  the  secretions.  Generally  an  unhealthy  condition  of  the 
mouth,  nose,  or.  throat  predisposes  to  the  disease,  as  a  lesion  of  the 
mucous  membrane  is  necessary  for  its  entrance.  The  bacilli  ^^ill  not 
grow  on  an  intact  mucous  membrane.  An  abrasion  must  be  present  for 
them  to  develop. 

There  is  a  non-^irulent  form  of  the  diphtheria  bacillus  which  differs 
in  a  number  of  respects  from  the  virulent  form,  both  in  its  culture  pecu- 
Harities  and  in  its  method  of  stainmg  ^^-ith  Hunfs  differential  stain,  and 
also  with  Neisser's  stain. 

Although  diphtheria  may  occur  at  any  age,  it  is  rarely  met  with  in 
early  infancy.  It  is  most  commonly  seen  from  the  second  to  the  fifth  or 
sixth  year.     It  mav  occur  more  than  once  in  the  same  individual. 


SPECIFIC    INFECTIOUS   DISEASES.  453 

Pathological  Anatomy. — The  lesions  of  diphtheria  are  due  to  the  local 
action  of  the  Klebs-Loeffler  bacillus  and  associated  bacteria,  and  to  the  ab- 
sorption of  toxins  produced  by  the  bacteria.  The  most  constant  lesion  is  a 
pseudo-membrane,  produced  by  the  local  action  of  the  bacilli  in  the  upper 
air-passages,  and  due  to  exudation  and  coagulation  necrosis.  The  exuda- 
tion coming  from  the  vessels  of  the  tissue  beneath  the  membrane  meets  the 
necrotic  tissue  containing  a  fibrin  ferment,  and  coagulation  takes  place, 
the  fibrin  of  the  coagulum  being  intimately  associated  with  the  necrotic 
epithelium.  The  bacilli  can  also  produce  other  lesions,  such  as  simple 
inflammation,  necrosis  without  membrane  formation,  and  even  abscess. 
There  is  no  pathological  condition  directly  characteristic  of  the  action  of 
the  Klebs-Loeffler  bacillus,  and  the  same  anatomical  conditions  may  be 
caused  by  other  bacteria,  and  even  by  irritants.  The  process  may  be 
simply  a  catarrhal  inflammation,  which  does  not  go  on  to  the  formation 
of  a  pseudo-membrane. 

The  primary  infection  in  diphtheria  is  most  commonly  in  the  throat, 
from  which  the  bacilli  may  extend  into  the  adjacent  mucous  surfaces,  pro- 
ducmg,  in  some  cases,  membrane  formation,  in  others  only  simple  or  puru- 
lent inflammation.  They  may  also  extend  into  the  nose,  producing 
nasal  diphtheria,  or  along  the  Eustachian  tubes  into  the  middle  ear,  or 
from  the  nose  into  the  accessory  sinuses,  downward  into  the  trachea 
and  air-passages,  or  into  the  oesophagus  and  stomach.  There  are  certain 
differences  in  the  membrane  formation  due  to  the  anatomical  character 
of  the  tissue.  Thus  the  membrane  in  the  pharynx  clings  tightly  to  the 
surface,  while  in  the  trachea  and  lower  passages  it  is  easily  removed. 

The  extension  of  the  bacilli  into  the  lungs  may  produce  a  membrane 
formation  in  the  smaller  bronchi,  areas  of  broncho-pneumonia  or  even 
abscesses.  The  pathological  process  may  be  further  modified  by  the 
association  with  the  Klebs-Loeffler  bacillus  of  the  common  pathogenic 
cocci,  and  it  is  difficult  to  determine  exactly  the  part  which  these  various 
organisms  play  in  the  production  of  the  local  lesions.  It  is  certain,  how- 
ever, that  the  lung  lesions  which  are  ordinarily  attributed  to  these  asso- 
ciated organisms  may  be  produced  by  the  Klebs-Loeffler  bacillus  alone. 

The  membrane  in  diphtheria  is  usually  of  a  peculiar  grayish- white 
color,  and,  as  a  rule,  cannot  be  easily  detached ;  in  some  cases,  on  the 
contrary,  it  may  be  white  and  easily  separated.  It  sometimes  assumes, 
early  in  the  disease,  a  gangrenous  appearance,  which  shows  that  the  case 
is  serious.  Nasal  diphtheria  is  characterized  by  a  profuse  nasal  discharge, 
and  often  by  a  membrane.  Transmission  of  the  germ  of  the  disease  from 
the  nose  to  the  eye  is  infrequent,  and  does  not  always  result  in  the  forma- 
tion of  a  false  membrane.  Frequently  the  pharyngeal  inflammation  ex- 
tends through  the  Eustachian  tube,  causing  inflammation  of  the  middle 
ear,  and  in  these  cases  a  membrane  may  be  formed.  The  membrane 
may  extend  downward  to  the  larynx,  causing  marked  dyspnea.  Below 
the  vocal  cords  the  membrane  is  not  very  firmly  attached,  and  is  fre- 


454  PEDIATRICS. 

quently  coughed  up.  If  death  occurs  late  in  the  disease  in  apparent  con- 
valescence no  macroscopic  lesions,  as  a  rule,  are  found.  Microscopic  ex- 
amination of  the  nerves,  however,  often  shows  marked  degeneration  of 
the  nerve  tissue. 

The  internal  lesions  of  the  disease  are  not  due  to  the  presence  of  the 
bacilli  but  to  the  action  of  the  toxic  substances  wliich  are  absorbed  from 
the  places  where  the  bacilli  are  growing.  These  lesions  consist  chiefly  in 
diffuse,  degenerative  changes,  and  in  intense  local  processes,  also  of  a  de- 
generative character.  The  organs  most  commonly  affected  by  these 
lesions  are  the  kidneys  and  the  lymph-nodes.  The  adjacent  lymph-nodes 
are  apt  to  be  swollen,  and  on  microscopical  examination  they  often  show 
small  foci  of  cell-necrosis  ;  smiilar,  smaller  necrotic  foci  may  be  found 
in  other  parts  of  the  economy,  as  m  the  liver,  and  are  due  to  absorp- 
tion of  toxins.  There  is  also  a  general  lymphatic  hyperplasia,  wliich  is 
relatively  greatest  in  the  abdomen.  The  kidneys  ordinarily  show  only 
pai'enchymatous  degeneration,  but  in  a  few  cases  of  concurrent  infection 
may  present  acute  lesions.  Hemorrhages  into  the  serous  membranes  are 
often  met  with,  and  the  organs  in  general  show  degenerative  changes  due 
to  action  of  the  toxins.  Endocarditis  is  rarely  seen.  Catarrhal  bronchitis 
and  Lironcho-pneumonia  frequently  complicate  diphtheria,  and  are  caused 
by  the  inspu'ation  of  the  pyogenic  cocci  as  well  as  by  the  mvasion  of  the 
Klebs-Loeffler  bacillus  itself. 

IxcuBATiox. — The  time  which  elapses  after  exposure  to  the  mfection 
until  the  first  symptoms  develop  may  be  only  twenty-four  hours  ;  on  the 
other  hand,  it  may  be  two  or  three  days.  This  period  of  incubation  is  a 
very  mdefinite  one,  since  the  interval  between  the  access  of  bacteria  to 
the  mucous  membrane  and  the  tmie  when  the  absorption  of  the  toxins 
becomes  apparent  depends  upon  whether  the  tissues  of  the  mucous  mem- 
brane are  vulnerable.  Thus,  it  is  probable  that  the  Klebs-Loeffler  bacillus 
may  exist  in  the  mouth  for  an  indefinite  time  without  infectmg  the  indi- 
vidual. 

Symptoms. — Diphtheria  must  be  considered  a  local  disease  at  the  onset, 
and  the  symptoms  that  occur  later  are,  like  the  secondary  pathological 
lesions,  the  result  of  the  absorj^tion  of  the  toxhi  caused  by  the  growth  of 
the  bacillus.  There  may  be  mild  forms  of  diphtheria  almost  without  con- 
stitutional symptoms.  The  severe  form  of  diphtheria  is  attended  by  grave 
general  prostration,  cardiac  depression,  and  aucemia.  is  frequently  compli- 
cated Avith  broncho-pneumonia  and  nephritis,  and  may  be  followed  by 
localized  or  general  paralysis.  The  constitutional  symptoms  are  not  due 
to  the  presence  of  the  Klebs-Loeffler  bacillus  m  the  blood. 

The  prodromal  symptoms  of  diphtheria  are  not  especially  tj^ical. 
They  may  be  acute  in  character,  or  ver}^  mild  and  of  a  subacute  variety. 
In  young  children  there  may  be  in  the  onset  of  the  disease  a  slight 
convulsion.  In  ceriain  cases,  according  to  McCollom,  a  peculiar  dark-red 
appearance  of  the  mucous  membrane  of  the  mouth  is  seen,   which  is 


SPECIFIC  INFECTIOUS  DISEASES.  455 

quite  characteristic.  There  is  apt  to  be  a  sensation  of  chilliness,  some 
heightening  of  the  temperature,  and  more  or  less  pain  in  the  back  and 
limbs.  There  is  nothing,  however,  to  distinguish  this  stage  from  many 
other  affections  of  children,  such  as  smiple  tonsillitis.  The  child  may 
often  complain  of  discomfort  on  swallowing,  and  on  examining  the  throat 
the  fauces  are  found  to  be  reddened.  In  ft-om  twelve  to  twenty-four 
hours,  however,  a  more  typical  appearance  will  be  seen  in  the  throat.  A 
white  or  grayish-white  pseudo-membrane,  commonly  appearmg  first  on 
the  tonsils,  develops,  and  on  the  second  or  third  day  extends  to  the 
soft  palate  and  uvula.  It  may  also  extend  backward  to  the  pharynx. 
During  this  stage  the  throat  becomes  much  swollen  and  the  tonsils  con- 
siderably enlarged,  so  as  almost  to  meet  at  times  in  the  median  line. 
The  diphtheritic  membrane  is  usually  fimily  adherent  to  the  mucous  mem- 
brane, and,  as  the  case  progresses,  assumes  a  brownish  or  yellowish-gray 
color,  sometimes  becoming  gangrenous,  ^Adth  an  extremely  foetid  odor.  A 
profuse  nasal  discharge  in  severe  cases  may  appear  at  this  stage,  and,  if 
the  patient  becomes  septic,  spots  of  ecchymoses,  which  are  of  grave  im- 
port, appear  on  various  parts  of  the  body,  and  are  usually  significant  of  a 
fatal  issue.  Listlessness  is  present,  but  delirium  of  an  active  type  is  not 
common.  An  efflorescence  resembling  scarlet  fever  may  appear  in  a  still 
later  stage.  In  addition  to  these  lesions  in  the  throat,  the  cervical  glands 
are  usually  mvolved  and  become  considerably  swollen.  The  child,  as  a 
rule,  shows  grave  constitutional  symptoms.  The  temperature  is  not 
characteristic.  It  is  usually  not  especially  high,  and  ranges  from  38.3°  to 
38.8°  C.  (101°  to  102°  F.).  It  may,  however,  rise  to  40°  C.  (104°  F.). 
A  subnormal  temperature  is  more  serious  than  a  moderately  elevated  one. 
The  pulse  is  somewhat  increased  in  rapidity,  and  is  weak  in  proportion 
to  the  severity  of  the  disease,  but  does  not  always  correspond  to  the  tem- 
perature ;  sometimes  it  is  very  slow.  The  slow  pulse  is  indicative  of  the 
action  of  the  toxin  on  the  nervous  centres,  as  well  as  to  the  weakness  of 
the  ventricles.  Diarrhoea  is  a  frequent  but  not  a  constant  symptom. 
Loss  of  appetite,  nausea,  and  vomiting  frequently  occur. 

In  cases  of  a  mild  type  the  symptoms  abate  towards  the  end  of  the 
first  week,  the  pseudo-membrane  separates,  leaving  a  raw  surface  behind 
it,  the  neck  becomes  less  swollen,  and  the  child  feels  much  better.  It  is, 
however,  usually  left  in  a  prostrated  condition  for  a  number  of  weeks ; 
and  even  in  these  mild  cases  the  toxic  effects  of  the  disease  may  show 
themselves  in  the  form  of  a  neuritis  with  an  accompanying  paralysis  many 
weeks  after  the  diphtheria  has  run  its  course.  There  may  also,  even  in 
mild  cases,  be  a  slight  discharge  from  the  nose,  owing  to  the  inflamma- 
tion of  the  posterior  nares.  Slight  albuminuria  is  not  mfrequent.  A 
very  prominent  symptom  in  all  forms  of  diphtheria  may  be  cardiac  weak- 
ness. In  some  cases  the  child  dies  suddenly  without  any  warning,  or 
death  may  have  been  preceded  by  attacks  of  semi-collapse.  In  other 
cases  there  may  be  a  weak  intermittent  pulse,  which  continues  through- 


456  PEDIATRICS. 

out  the  disease  and  during  convalescence.  Under  these  circumstances  the 
child  should  be  considered  to  be  in  a  critical  condition,  as  death  is  likely 
to  occur  suddenly. 

The  following  case  represents  one  of  the  milder  forms  of  diphtheria : 

A  boy,  five  years  old,  had  been  sick  four  days.  His  pulse  was  Somewhat  rapid, 
but  of  good  strength.  His  respirations  were  slightly  increased.  There  was  no  thoracic 
retraction.  There  was  a  slight  discharge  from  the  nose,  and  the  cervical  glands  were 
somewhat  enlarged.  He  took  his  nourishment  well,  and  seemed  in  a  very  fair  condi- 
tion. The  urine  contained  a  small  amount  of  albumin.  An  examination  of  the  throat 
showed  small  patches  of  grayish-white  pseudo-membrane  on  the  upper  part  of  the  left 
tonsil,  and  corresponding  to  the  left  arch  of  the  soft  palate.  This  is  represented  in 
Plate  XL.  facing  page  620.  The  membrane  had  also  involved  the  right  side  of  the 
uvula,  the  right  arch  of  the  soft  palate,  and  the  side  of  the  right  tonsil  pointing  towards 
the  median  line.  There  was  also  a  patch  on  the  right  tonsil  and  on  the  posterior  wall 
of  the  pharynx.  The  tonsils  were  moderately  enlarged  and  reddened,  and  the  mucous 
membrane  of  the  soft  palate  was  considerably  inflamed.  When  lesions  of  this  character 
and  description  are  seen  in  the  throat,  there  can  seldom  be  any  doubt  as  to  the  clinical 
diagnosis  of  diphtheria,  and  a  bacteriological  examination  should  at  once  be  made. 
In  this  case  a  culture  made  on  Loeffler's  blood-serum  of  a  shred  of  membrane  taken 
from  the  throat  showed  the  presence  of  the  Klebs-Loeffler  bacillus  and  a  large  number 
of  streptococci. 

Variations  in  Type. — There  are  a  number  of  variations  which  occur 
both  in  the  severity  of  the  disease  and  in  the  locality  which  is  first 
attacked  or  principally  invaded. 

Atypical  Infections  of  the  Throat. — In  some  epidemics  the  Klebs- 
Loeffler  bacillus  seems  to  be  far  more  virulent  than  in  others,  and  in 
some  individuals  it  produces  much  more  serious  symptoms  than  in 
others.  The  severity  of  the  attack  does  not  always  depend  upon  the 
extent  of  the  pseudo-membrane.  In  general,  the  severity  of  the  cases 
depends  on  three  factors :  (1)  the  virulence  of  the  bacteria,  (2)  the  local 
resistance,  and  (3)  the  general  resistance.  A  number  of  what  may  be 
called  atypical  cases  have  been  observed  and  carefully  studied,  especially 
by  Koplik,  in  which  no  pseudo-membrane  was  detected  and  in  which  the 
morbid  appearances  in  the  throat  were  those  of  a  simple  catarrh  or  fol- 
licular tonsillitis.  The  virulent  Klebs-Loeffler  bacillus  was  detected  in 
these  cases,  and  other  children  infected  by  them  presented  the  typical 
local  lesions  of  diphtheria. 

Malignant  Forms  of  Diphtheria. — In  addition  to  these  mild  cases,  the 
Klebs-Loeffler  bacillus  at  times  produces  a  most  malignant  form  of  diph- 
theria. In  these  cases  the  child  either  shows  a  fairly  mild  form  of  the 
disease  for  a  few  days  and  then  suddenly  develops  the  severe  form,  or  it 
may  be  attacked  at  once  by  very  severe  symptoms.  It  becomes  dull ; 
the  temperature  is  either  slightly  raised  or  may  rise  to  39.4°  or  40°  C. 
(103°  or  104°  F.),  or  higher;  the  pseudo-membrane  spreads  rapidly: 
there  may  be  a  dusky  efflorescence  on  the  skin,  simulating  closely  that 
which  has  been  described  in  the  malignant  form  of  scarlet  fever.     There 


SPECIFIC  INFECTIOUS   DISEASES.  457 

may  also  be  a  purpuric  condition  of  the  skin.  The  picture  of  these  septic 
cases  is  very  characteristic.  There  is  a  peculiar,  sweetish  odor  to  the 
breath.  .  There  are  cyanosis  and  a  marked  waxy  pallor.  There  are 
hemorrhages  from  the  throat  and  nose,  with  a  profuse  muco-purulent 
discharge  from  the  latter.  The  cervical  glands  are  often  enormously  en- 
larged. The  membrane  has  been  known  to  extend  in  all  directions,  and 
sometimes  even  through  the  Eustachian  tubes  to  the  external  ears.  All 
degrees  of  severity  are  met  with  between  the  mild  and  malignant  types 
of  diphtheria.  The  membrane,  instead  of  extending  upward  to  the  naso- 
pharynx, as  occurs  in  the  malignant  cases  just  spoken  of,  may  spread 
downward,  attacking  the  epiglottis  and  the  larynx,  and  cause  serious 
obstruction.  The  pseudo-membrane  most  commonly  appears  first  on  the 
tonsils,  thence  spreading  to  the  soft  palate  and  to  the  uvula.  The  disease 
may,  however,  begin  in  the  mucous  membrane  of  any  part  of  the  mouth, 
nose,  or  throat. 

Nasal  Diphthena. — Diphtheria  sometimes  l^egins  in  the  nose  and 
spreads  no  farther.  Primary  nasal  diphtheria  may  be  either  very  mild  or 
very  severe,  according  to  where  the  membrane  is  situated.  If  the  mem- 
brane forms  in  the  anterior  nares  the  probability  of  absorption  is  reduced 
to  a  minimum,  and  there  is  usually  very  little  constitutional  disturbance. 
The  condition  is  especially  liable  to  be  overlooked,  as  the  child  for  one  or 
two  days  may  show  merely  the  symptoms  of  fever,  malaise,  loss  of  appe- 
tite, and  a  discharge  from  the  nose.  On  examining  the  nose  carefully, 
however,  a  pseudo-membrane  will  often  bo  found.  It  is,  therefore,  very 
important  in  cases  of  this  kind  to  have  a  bacteriological  examination  made, 
and  lo  isolate  the  child  until  it  is  determined  that  the  Klebs-Loeffler 
bacillus  is  not  present.  These  cases  are  a  prolific  source  of  infection  to  the 
community  at  large,  for  even  when  antitoxin  has  been  given  it  does  not  kill 
the  bacilli,  although  it  may  stop  the  nasal  discharge. 

According  to  McCollom  the  importance  of  nasal  diphtheria  of  this  type 
is  the  danger  of  communicating  the  disease  to  others.  The  history  of 
many  serious  outbreaks  of  diphtheria  is  due  to  the  fact  that  some  member 
of  a  family  or  some  inmate  of  an  institution  has  had  a  profuse  discharge 
from  the  nose  Avithout  any  constitutional  disturbance,  and  has  been  the 
focus  from  which  has  arisen  many  severe  cases  of  diphtheria.  This  is  not 
a  theoretical  statement,  but  is  the  result  of  experience.  Every  profuse  dis- 
charge from  the  nose,  particularly  if  there  is  any  excoriation  about  the 
nostrils,  should  be  looked  upon  with  suspicion  and  cultures  should  be 
taken.  If  adenoids  are  to  be  removed,  cultures  should  always  be  taken 
before  the  operation  is  performed,  for  it  very  frequently  happens  that  a 
child  who  has  a  profuse  discharge  from  the  nose  immediately  after  the 
removal  of  adenoids  or  the  ablation  of  the  tonsils,  has  a  severe  attack  of 
diphtheria.  If  the  operation  for  cleft  palate  is  to  be  performed,  it  is  still 
more  important  to  take  cultures;  because,  if  there  are  any  bacilli  of 
diphtheria  in  the  nasal  discharge,  this  organism  is  sure  to  grow  upon  the 


458  t>EDIATRICS. 

cut  surfaces  of  the  operative  tract,  and  the  patient  not  only  has  an  attack 
of  diphtheria,  which  may  be  mild  or  severe,  but  also  the  edges  of  the 
wound  slough  and  render  a  second  operation  much  more  difficult. 

A  chronic  rhinitis  may  follow  an  attack  of  diphtheria  ;  and  on  the  other 
hand  a  patient  with  a  chronic  rhinitis,  if  exposed  to  diphtheria,  is  very 
likely  to  contract  the  disease.  Laboratory  experiments  have  shown  con- 
clusively that  the  bacilli  of  diphtheria  will  not  grow  on  intact  mucous 
membrane,  and  therefore  it  is  a  self-evident  proposition  that  all  abnormal 
conditions  of  the  mucous  membrane  of  the  nose  should  be  corrected,  if 
possible,  by  treatment.  It  is  a  well-known  fact  that  diphtheria  is  preva- 
lent in  New  England,  and  it  is  reasonable  to  suppose  that  the  frequency  of 
the  disease  is  due  to  the  fact  that  the  mucous  membrane  of  the  nose  and 
throat  of  individuals  in  this  locality  is  in  a  morbid  condition.  The  charac- 
teristic nasal  voice  of  New  England  proves  the  truth  of  the  foregoing 
statement. 

While  adenoids  may  not  render  an  individual  particularly  susceptible 
to  diphtheria,  yet,  if  he  contracts  the  disease,  he  is  much  more  likely  to 
have  a  severe  attack  than  a  person  without  these  abnormal  growths.  The 
persistence  of  positive  cultures  after  recovery  from  the  acute  symptoms  is 
very  frequently  due  to  this  condition  of  the  naso-pharynx. 

When  the  disease  is  situated  in  the  posterior  nares  and  the  naso- 
pharynx is  affected,  either  primarily  or  secondarily  through  the  nares  or 
the  pharynx,  the  constitutional  symptoms  are,  as  a  rule,  marked.  This  is 
in  all  probability  accounted  for  by  the  great  mass  of  absorbents  in  the 
naso-pharynx,  where  absorption  takes  place  so  easily  that  general  septic 
poisoning  quickly  follows  with  often  fatal  result.  In  these  cases  the  toxin 
generated  is  very  readily  absorbed  and  causes  death  from  its  effects  on  the 
heart.  Many  patients  die  from  unrecognized  nasal  diphtheria,  because  no 
membrane  is  seen,  and  the  first  indication  of  serious  trouble  is  a  rapid 
action  of  the  heart  known  as  the  bruit  de  galop,  or,  in  some  instances,  there 
may  be  a  slow  pulse,  and  the  physician  is  often  unable,  if  he  does  not 
have  the  idea  of  nasal  diphtheria  in  mind,  to  explain  the  symptoms. 

Laryngeal  Diphtheria. — In  some  cases  the  Klebs-Loeffler  bacillus  pro- 
duces its  effects  first  on  the  mucous  membrane  of  the  larynx.  In  these 
cases  the  mucous  membrane  of  the  nose  and  pharynx  may  never  show 
any  evidence  of  a  pseudo-membrane.  The  first  symptom,  as  a  rule,  is  a 
cough  of  a  harsh,  ringing  nature.  The  temperature  may  or  may  not  be 
raised.  As  the  toxic  absorption  is  slight,  on  account  of  the  locality 
affected,  the  constitutional  symptoms  are  correspondingly  mild.  The 
child's  symptoms  are  those  resulting  from  laryngeal  obstruction.  There 
is  dyspnoea,  with  retraction  of  the  intercostal  and  supraclavicular  spaces, 
and  later  of  the  epigastrium  and  the  lower  chest.  This  is  accompanied 
by  an  increasing  cyanosis.  The  child  is  very  restless,  is  forced  to  sit  up 
in  order  to  breathe,  and,  for  the  same  reason,  bends  forward  with  its  head 
back.     In  these  extreme  cases,  unless  relief  is  speedily  afforded,  the  child 


SPECIFIC  INFECTIOUS  DISEASES.  459 

soon  dies  of  suffocation.  In  another  set  of  cases  a  slower  form  of  suffo- 
cation may  result  from  the  extension  of  the  membrane  downward  to  the 
bronchi,  while  in  still  another  set  death  may  result  from  a  complicating 
broncho-pneumonia. 

In  diphtheria  of  the  larynx  there  may  be  laryngeal  stenosis,  and  yet 
no  membrane  be  ^'isible,  and  the  cultures  taken  during  life  may  be  nega- 
tive. In  almost  every  instance,  however,  these  cases  are  shown  to  be 
diphtheria  at  the  autopsy.  Streptococci  may  cause  a  membrane  in  the 
air-passages,  but  a  membrane  of  such  an  origin,  as  a  rule,  is  not  suffi- 
ciently tough  or  thick  to  impede  respiration.  Attacks  of  laryngeal  dys- 
pnoea may  occur  very  suddenly,  even  in  mild  cases  of  diphtheria. 

Complications  and  Sequelae. — There  are  a  number  of  complications 
which  arise  in  diphtheria  besides  those  of  laryngeal  stenosis  and  cardiac 
weakness.  The  most  serious  of  these  are  bronchopneumonia  and  acute 
nephritis. 

Lung-. — The  form  of  pneumonia  which  complicates  diphtheria  is 
broncho-pneumonia,  which  is  produced  not  only  by  the  Klebs-Loeffler 
bacillus,  but  by  pyogenic  cocci  which  have  been  inspired.  Broncho- 
pneumonia is  most  frequent  and  most  fatal  in  laryngeal  cases  which  have 
been  operated  upon. 

Kidney. — Albuminuria  is  so  commonly  met  with  in  both  the  mild  and 
the  severe  cases  of  diphtheria  that  it  should  be  considered  as  a  part  of  the 
disease  rather  than  as  a  complication  ;  as  a  rule,  the  greater  the  amount  of 
albuminuria  the  more  severe  the  case.  When  acute  nephritis  complicates 
diphtheria  it  is  not  usually  accompanied  by  oedema  or  anasarca. 

Ear. — Secondary  diphtheria  of  the  ear,  caused  by  the  excursion  of  the 
specific  organism  from  the  throat  to  the  nasal  passages,  and  thence  to  the 
ear,  through  the  Eustachian  tube,  occurs  very  frequently,  and  improper 
methods  of  treatment,  such  as  unwise  irrigation,  increase  the  danger  of  ear 
complications.  Feeding  through  the  nose,  according  to  McCollom,  as  in 
cases  of  intubation,  frequently  causes  otitis  media,  and  although  in  certain 
rare  cases  is  advisable,  in  the  majority  of  cases  it  is  better  to  resort  to 
oesophageal  feeding  or  to  the  Casselberry  method. 

The  bacilli  of  diphtheria  frequently  remain  for  a  long  time  in  the  aural 
discharge,  although  they  may  not  give  rise  to  any  symptoms.  In  many  in- 
stances, however,  a  bacillus  morphologically  resembling  the  bacillus  of  diph- 
theria is  found  in  this  discharge.  This  organism  has  been  very  frequently 
mistaken  for  that  of  diphtheria.  Its  life  history  is  entirely  different  from 
that  of  the  bacillus  of  diphtheria.  It  is  very  doubtful,  if  proper  care  is 
taken,  if  a  patient  with  the  bacilli  of  diphtheria  in  the  ear  can  communicate 
the  disease  to  others.  The  conditions  are  entirely  different  when  a  patient 
has  the  bacilli  of  diphtheria  in  the  nose  or  in  the  throat. 

Among  the  more  common  sequelae  are  secondary  anaemia  and  chronic 
naso-pharyngeal  catarrh.  The  most  common  and  serious  sec|uela  of 
diphtheria   is   a    peripheral    neuritis.,    with    its   accompanying   paralysis. 


460  PEDIATRICS. 

This  paralysis  often  does  not  appear  until  convalescence  has  been 
established,  perhaps  in  the  third  or  fourth  week  from  the  time  of 
the  attack.  It  may  show  itself  in  the  form  of  a  palatal  paralysis 
of  such  an  extent  as  not  only  to  cause  a  nasal  voice,  but  to  allow 
the  passage  of  fluids  through  the  nose.  The  child  may  die  of  inanition 
from  inability  to  swallow,  and  may  recjuire  to  be  fed  with  the  head  low- 
ered or  by  the  stomach-tube.  Inability  to  read,  dilated  pupils,  and  double 
vision  may  arise  from  ocular  paralysis.  There  may  also  be  a  more  gen- 
eral distribution  of  the  paralysis,  the  child  only  being  able  to  raise  its 
head  or  move  its  limbs  to  a  limited  extent.  Again  there  may  be  a  pe- 
ripheral neuritis  with  marked  pain.  In  the  more  severe  cases  the  lower 
extremities  are  affected,  and  the  knee-jerks  are  absent.  When  the  limbs 
are  involved  the  electrical  reactions  are  the  same  as  in  peripheral  neuritis 
from  other  causes. 

Diagnosis. — The  local  lesions  produced  by  the  Klebs-Loeffler  bacillus 
may  be  merely  a  catarrhal  inflammation  or  those  of  a  follicular  ton- 
sillitis. All  such  conditions,  therefore,  should  be  looked  upon  with  sus- 
picion until  the  absence  of  the  Klebs-Loeffler  bacillus  has  been  demon- 
strated bacteriologically.  Although  a  membranous  laryngitis  may  be  due 
to  other  causes  than  the  Klebs-Loeffler  bacillus,  yet  this  is  so  rare  that 
every  case  of  primary  membranous  laryngitis  should  be  considered  to  be 
diphtheria  until  it  has  been  proved  that  it  is  not.  A  decisive  diagnosis  of 
diphtheria  in  any  case  can  only  be  made  by  determining  the  presence  of 
the  Klebs-Loeffler  bacillus. 

Recognizing  that  the  same  pseudo-membranous  condition  in  the  throat 
may  occasionally  be  produced  by  pyogenic  cocci  as  well  as  by  the  Klebs- 
Loeffler  bacillus,  the  clinical  diagnosis  of  a  typical  case  of  diphtheria  is 
often  difficult.  A  provisional  diagnosis  of  diphtheria  should  be  based 
upon  the  appearance  of  the  throat  of  a  pseudo-membrane  which  usually 
appears  first  on  the  tonsils,  and  has  a  tendency  to  spread  to  the  uvula, 
soft  palate,  and  pharynx.  When  in  addition  to  this  a  nasal  discharge 
is  present,  and  the  glands  of  the  neck  are  much  enlarged,  a  picture  is 
presented  which  is  not  shown  by  any  other  disease.  The  most  common 
difficulty  met  with  clinically  is  in  distinguishing  between  cases  of  acute 
follicular  tonsillitis  and  diphtheria.  In  taking  a  culture,  as  has  been 
pointed  out  by  McCollom,  a  source  of  error  in  results  is  that  the  swab  or 
platinum  needle  is  rubbed  over  the  surface  of  the  membrane,  a  locality 
where  the  organism  is  most  Kkely  to  die.  The  edge  or,  if  possible,  the 
under  surface  of  the  membrane  are  the  proper  places  from  which  to  take 
cultures.  Cultures  should  also  be  taken  from  the  secretions  of  the  mouth 
and  from  the  nasal  discharge.  Antiseptic  gargles  and  applications  should 
not  be  used  a  short  tmie  before  the  culture  is  taken. 

Efflorescences  of  urticaria  and  various  forms  of  erythema  may  follow 
antitoxin,  and  even  ecchymoses.  Efflorescences  may  occur  resembling 
scarlet  fever  and  measles,  often  so  closely  that  the  most  careful  examina- 


SPECIFIC    INFECTIOUS   DISEASES.  461 

tioii  and  consideration  of  the  symptoms  are  necessary,  and  even  tlien  the 
differential  diagnosis  is  often  impossible.  Scarlet  fever  is  differentiated  by 
the  presence  of  fever,  vomiting,  and  the  characteristic  appearance  of  the 
throat  and  tongue  :  measles  by  the  absence  of  catarrhal  symptoms  and 
from  the  fact  that  the  antitoxin  efflorescence,  as  a  rule,  first  appears  on 
the  extremities.  The  efflorescence  from  antitoxin  may  for  a  few  days 
render  the  patient  uncomfortable,  but  the  symptoms  pass  off  just  as  an 
urticaria  does  Avhen  resulting  from  one  of  its  excitmg  causes. 

Prognosis. — Diphtheria  is  an  extremely  fatal  disease,  especially  in  the 
septic  and  obstructive  cases.  The  mortality  varies  decidedly  in  different 
epidemics  and  according  to  the  age.  The  mortality  is  greatest  in  cliildren 
under  two  years  of  ag'e.  but  has  been  lessened  in  cases  in  which  the  anti- 
toxin treatment  has  been  thoroughly  used.  In  the  acute  stage  death  may 
occur  either  from  laryngeal  stenosis  or  by  the  toxin  generated  from  the 
growth  of  the  bacillus.  In  the  later  stages  or  during  convalescence  it 
may  be  due  to  the  action  of  the  toxin  on  the  nervous  centres.  Thus  paral- 
ysis of  the  pneumogastric  nerve  with  obstinate  vomiting  and  heart  failure 
is  a  frequent  cause  of  death,  occurring  during  apparent  convalescence. 
The  symptoms  wiiich  make  the  prognosis  especially  unfavorable  are  the 
extension  of  the  membrane  to  the  naso-pharynx  or  the  larynx,  profuse 
nasal  discharge,  marked  septic  odor,  extensive  glandular  enlargement, 
hemorrhage  from  the  nose  or  into  the  skin,  a  high  grade  of  albuminuria, 
broncho-pneumonia,  and  a  weak  heart.  Morse,  in  an  extensive  study  of 
the  leucocytosis  "of  diphtheria,  has  shown  that  it  has  no  prognostic  value. 
In  cases  of  post-diphtheritic  paralysis  the  prognosis  is  good,  as  they  almost 
invariably  recover.  The  prognosis  in  all  cases  of  diphtheria  is  uncertain 
and  should  be  given  with  caution,  and  no  case  of  diphtheria  should  be 
considered  benign,  for  at  times  in  certain  mild  cases  serious  symptoms 
of  paralysis  may  arise,  and  death  from  heart  failure  is  liable  to  occur  at 
any  stage  of  the  disease.  A  child  who  has  had  diphtheria  is  liable  to 
suffer  from  the  deleterious  effects  of  the  disease  for  months  and  even 
years.  Before  antitoxin  was  used  the  mortality  from  diphtheria  in  the 
City  Hospital  was  50  per  cent.  Since  its  use  in  a  series  of  4500  cases  in 
the  diphtheria  wards  of  the  Boston  City  Hospital  the  mortality  has  been 
reduced  to  13  per  cent.,  and  when  the  moribund  cases,  which  numbered 
179,  by  wliich  are  meant  those  dying  \\ithin  twenty-four  hours  after  ad- 
mission to  the  hospital,  are  deducted  the  mortality  was  about  10  per  cent. 

Prophylaxis. — All  patients  with  diphtheria  should  be  isolated  until 
the  Klebs-Loeffler  bacillus  has  cUsappeared  from  the  nose  and  throat.  The 
time  when  this  occurs  varies  from  a  few  days  to  a  number  of  weeks. 

In  order  further  to  protect  the  community,  all  cases  of  sore  throat 
should  be  examined,  and  if  the  Klebs-Loeffler  bacillus  is  found  the  patient 
should  be  isolated.  It  is  especially  necessary  to  carry  out  this  precaution 
in  schools,  where  the  conditions  are  so  favorable  for  the  spread  of  the 
disease. 


462  PEDIATRICS 

The  throats  and  noses  of  all  persons  exposed  to  diphtheria  or  caring 
for  diphtheritic  patients  should  be  repeatedly  examined  for  the  Klebs- 
Loeffler  bacillus,  and  if  this  is  found  they  should  be  given  immunizing 
doses  of  antitoxin,  the  amount  and  frequency  of  the  doses  to  be  modified 
as  our  knowledge  increases.  If  the  Klebs-Loeffler  bacillus  is  found  in 
these  individuals,  they  should  be  isolated  so  long  as  the  bacillus  is  pres- 
ent. To  shorten  the  period  of  isolation,  mild  antiseptic  gargles  or  douches 
should  be  employed.  It  is  very  important  to  keep  the  teeth  in  good  con- 
dition as  a  prophylactic  measure,  as  well  as  the  mucous  membrane  of  the 
nose  and  throat.  Whether  the  isolation  of  healthy  persons  who  have  the 
Klebs-Loeffler  bacillus  in  their  throat  or  nose  is  advisable  or  not  is  still  a 
mooted  question.  Much  confusion  has  arisen  because  of  the  so-called 
pseudo-diphtheritic  bacillus.  The  weight  of  evidence  at  present,  however, 
goes  to  show  that  it  does  not  exist,  and  that  the  bacteria  described  are 
merely  Klebs-Loeffler  bacilli  of  diminished  virulence.  At  any  rate,  even 
if  the  pseudo-diphtheritic  bacillus  exists,  it  is  so  rare  that  it  may  "be 
safely  excluded  in  clinical  work.  The  fact  that  the  Klebs-Loeffler  bacilli 
found  in  healthy  throats  may  not  be  virulent  is  not  an  argument  against 
isolation,  because  it  is  M^ell  known  that  a  non-virulent  form  may  become 
virulent  when  transferred  to  a  different  soil.  Examinations  of  many 
healthy  throats  have  shown  that  the  Klebs-Loeffler  bacillus  is  a  very  rare 
inhabitant  of  the  normal  throat,  and  that  when  it  is  present  diphtheria 
often  develops  later.  Theoretically,  therefore,  although  it  may  be  impos- 
sible or  inadvisable  practically,  it  would  seem  wise  to  consider  the  Klebs- 
Loeffler  bacillus  virulent  until  it  has  been  proved  to  be  non-virulent,  and 
to  consider  its  presence  a  source  of  danger  to  the  community  until  it  is 
proved  not  to  be. 

When  an  individual  has  been  exposed  to  the  contagium  of  diphtheria, 
immunization  can  be  accomplished  by  the  injection  of  antitoxin  in  doses 
varying  according  to  the  age.  Thus,  at  six  months  the  immunizing  dose 
for  infants  is  500  units,  and  for  older  children  1200  units.  The  immuni- 
zation lasts  for  from  twenty-eight  to  thirty  days. 

The  practice  of  immunization  of  hospital  patients  to  prevent  outbreaks 
of  diphtheria  has  proved  highly  successful.  At  the  Children's  Hospital, 
from  May  1,  1897  to  October  1,  1905,  10,575  patients  were  treated,  and  at 
the  Infants'  Hospital,  from  February  1,  1900,  to  October  1,  1905,  1276 
cases  were  treated.  During  these  years  no  case  of  diphtheria  broke  out  in 
the  wards.  It  has  been  our  custom  to  give  500  units  to  infants  and  1000 
to  1500  to  children  once  in  three  weeks.  No  serious  results  have  en- 
sued from  this  practice.  Urticarial  rashes  and  occasional  cases  of  mild 
cellulitis  have  been  the  only  unpleasant  effects  noticed. 

The  length  of  time  before  a  child  who  has  had  diphtheria  may  cease 
to  be  a  source  of  contagion  should  be  determined  by  three  consecutive 
negative  cultures  from  the  nose  and  throat  with  twenty-four  or  forty-eight 
hour  intervals. 


SPECIFIC   INFECTIOUS   DISEASES.  463 

The  greatest  care  should  be  taken  both  by  the  physician  and  tlie  nurse 
not  to  become  infected  themselves  by  the  secretions  from  the  mouth  and 
nose  of  the  patient.  Especial  care  should  be  taken  to  avoid  getting  these 
secretions  into  the  eyes.  It  is  probable  that  with  extreme  care  there  is 
not  much  danger  of  the  spread  of  diphtheria  in  a  household,  as  we  know 
its  tendency  is  not  to  disseminate  itself  in  the  surrounding  atmosphere, 
hence  it  is  likely  that  with  proper  precautions  it  can  be  confined  to  the 
room  in  which  the  child  is  sick,  and  that  if  the  epidemic  extends  beyond 
this  room  it  has  been  carried  directly  by  the  hands  or  clothing  of  the 
nurse  or  physician. 

The  room  should  be  cleared  of  hangings  and  all  stufled  furniture,  car- 
pets, and  clothes.  The  hands  of  the  attendants  should  be  disinfected. 
No  handkerchiefs  should  be  used ;  pieces  of  cotton  cloth,  which  can  be 
destroyed  by  fire,  are  to  be  preferred.  Discharges  should  be  disinfected 
with  carbolic  acid  1  to  20 ;  mattresses,  blankets,  and  utensils  should  be 
steamed.  The  floors  and  woodwork  should  be  washed  with  corrosive 
sublimate  1  to  500.  Books  and  toys  should  be  destroyed,  as  there  is  no 
way  of  disinfecting  these  articles.  Upholstered  furniture  should  be  im- 
mersed in  boiling  naphtha  for  two  or  three  hours.  The  boiling-point  of 
naphtha  is  79.4°  C.  (175°  F.),  and  is  lower  than  the  melting-point  of  glue. 
The  vapor  of  formaldehyde  is  one  of  the  most  valuable  germicides.  Gen- 
eral disinfection  of  the  room  is  described  in  the  disinfection  of  scarlet 
fever,  page  558.  Pure  air  and  plenty  of  sunlight  are  the  most  effective 
germicides.  It  is  important  to  isolate  doubtful  cases,  especially  when  the 
symptoms  are  associated  with  a  profuse  nasal  discharge. 

Treatmext. — The  treatment  of  diphtheria  consists  (1)  in  attending  to 
the  hygiene  and  to  measures  directed  to  the  general  condition  ;  (2)  in  the 
administration  of  remedies,  either  by  the  skin  or  by  the  mouth,  to  combat 
the  toxin  which  is  producmg  the  constitutional  symptoms  ;  (3)  in  local 
apphcations  to  the  nose,  throat,  or  lar}^nx  ;  and  (4)  in  operative  measures 
to  relieve  obstruction  in  the  lan^nx. 

General  Hygiene, — One  of  the  most  important  parts  of  the  treatment 
of  diphtheria  is  the  management  of  the  room  in  wiiich  the  patient  is  kept 
during  the  progress  of  the  disease.  It  is  known  that  pathogenic  organ- 
isms, such  as  the  Klebs-Loeffier  bacillus,  do  not  thrive  where  they  are 
exposed  to  sunlight  and  fresh  air.  The  room  should  therefore  be 
thoroughly  ventilated,  and  fresh,  pure  air  should  be  allowed  to  come 
continuously  into  it.     It  should  also  be  one  which  has  a  sunny  exposure. 

Stimulation. — In  any  treatment  directed  to  the  cure  of  diphtheria  in 
young  children,  we  must  remember  that  the  disease  is  so  exhaustmg  that 
the  treatment,  as  a  rule,  should  be  forced  upon  the  child  as  little  as  possi- 
ble. Any  physical  exhaustion  produced  by  the  treatment  is  to  be  con- 
sidered serious  in  young  children.  Diphtheria  is  such  a  depressing  dis- 
ease that  alcohol  should  be  given  from  the  onset,  and  the  amount  should 
be  relatively  large.     Either  whiskey  or  brandy  are  valuable  stimulants. 


464 


PEDIATRICS. 


For  a  child,  one  or  hvo  years  old,  it  is  well  to  begin  A\-ith  7.50  c.c.  (2 
dracliins)  every  four  hours,  watching  the  pulse  and  general  condition. 
When  there  are  indications  of  beginnhig  heart  failure,  digitalis  is  indicated 
early  m  the  disease,  and  strychnine  later.  When  there  is  collapse,  nitro- 
glycerin should  be  given.  Atropine  is  recommended  as  sometimes  givmg 
great  relief  when  much  mucus  collects  in  the  air-passages. 

The  following  table  has  been  arranged  to  show  the  small  and  large 
doses  of  digitalis,  strychnine,  nitro-glycerin,  and  atropme,  which  may  be 
used  at  different  ages  : 

TABLE  58. 


1 

Age. 

Tinctiire 

Strvchnine. 

Xitro-Glycerin. 
1  per  cent,  colution.    , 

Atropine. 

Digitalis. 

(1  minim  =  ^^  grain.) 

Mhiims. 

Grain. 

Minims. 

Grain. 

3  months. 

i^to    ^ 

2000     ^'-^     1000 

tV  to  J^ 

To 00    to    1500 

6  months. 

iVto  i 

TToo   to    Th 

A  to  xV 

2  300    to   YS^V 

9  montlis. 

1  tol 

1           fn           1 
1000     ^^       3  0tf 

A  to  ^ 

rsoJf  to    >4-^ 

1-2  months. 

I  toli- 

rk   to   ^ 

To  to    i 

1000.  to     -g^ij 

2  vears. 

1  to  2 

o^    to    xig 

tV  to   1 

T*T7     to     ^k 

3  years. 

I  to  3 

300    to    iJu 

tV  to    1 

'do    to    ^l^ 

i  to  10  vears. 

1    to  5 

2^   to    ^V 

J    to    1 

2*0    to    li^ 

10  to  12  yeaK. 

3    to  8 

iJo    to     ^\ 

I    tol 

1        to        1 
2^0      ^     TOTT 

Sermn-Therrapy. — The  treatment  which,  according  to  our  present 
knowledge,  is  most  efficacious  in  diphtheria,  is  essentially  comprised  un- 
der serum-therapy. 

By  serum-therapy  is  meant  the  treatment  of  the  disease  by  hijecting 
into  the  patient  the  scrum  of  an  animal  ^vhich  has  been  rendered  immune 
to  the  special  disease  which  is  being  treated  by  means  of  inoculation 
with  the  toxin  of  that  disease.  The  serum  taken  from  the  animals  which 
have  been  rendered  iminune  to  diphtheria  has  been  called  the  antitoxin 
serum.  The  serum  can  be  injected  under  the  skin.  The  place  selected 
should  always  be  one  on  which  pressure  is  not  exerted  when  lying  in 
bed. 

The  dose  of  antitoxin  serum  of  diphtheria  should  be  from  1000  to 
3000  units,  according  to  the  age  of  the  child  and  the  severity  of  the 
disease.  McCollom  prefers  the  use  of  from  4000  to  8000  units.  The 
unit  is  the  same  in  all  reliable  preparations. 

The  beneficial  results  of  antitoxin  are  decidedly  greater  if  the  injec- 
tion is  made  in  an  early  stage  of  the  disease  than  if  later,  although  even 
when  administered  late  in  the  disease  it  sometimes  produces  wonderfully 
curative  effects.  When  given  early,  within  the  first  forty-eight  hours  of 
the  disease,  even  when  the  membrane  is  spreading  rapidly,  and  inflam- 
mation of  the  slands  with  general   systemic  poisoning  has  taken  place. 


SPECIFIC   INFECTIOUS   DISEASES.  465 

one  injection  will  often  arrest  the  disease.  When  improvement  does  not 
take  place  within  six  or  eight  hom-s,  a  second  dose,  and  if  necessary  a 
larger  one  should  be  used.  Thus,  if  the  dose  was  2000  units,  after  eight 
hours  a  second  dose  of  2000  or  3000  units  should  be  given,  the  latter  in 
the  more  severe  cases.  In  these  very  severe  cases  even  much  larger 
doses  may  be  given  and  at  shorter  intervals. 

The  signs  by  which  we  know  that  the  antitoxin  serum  has  produced 
a  beneficial  result,  are  indicated  by  the  improvement  in  the  general  con- 
dition of  the  patient,  and  the  effect  of  the  antitoxin  on  the  pseudo-mem- 
brane, which  is  characteristic.  The  dose  should,  therefore,  be  repeated 
if  the  general  condition  and  the  throat  do  not  improve  in  eight  hours. 
If  at  the  end  of  twenty-four  hours  the  membrane  has  not  begun  to  roll 
up  at  the  edges,  and  the  cervical  glands  have  not  diminished  in  size,  and  if 
a  profuse  nasal  discharge  with  a  septic  odor  is  present,  a  thii'd  dose,  and 
perhaps  a  fourth  or  fifth  dose,  may  be  required.  When  the  antitoxin  has 
produced  its  characteristic  effect,  the  pseudo-membrane  besides  rolling  up 
at  the  edges,  ceases  to  spread,  whitens,  shrinks,  shows  a  line  of  demarka- 
tion,  and  usually  within  the  next  three  or  four  days  becomes  detached 
fi'om  the  mucous  membrane. 

The  temperature  sometimes  rises  after  the  injection  of  antitoxin,  and 
in  a  few  days  falls  to  the  normal  by  lysis.  In  the  more  severe  cases  a 
single  injection  of  the  serum  does  not  work  so  quickly.  In  these  cases 
the  temperature  falls  usually  by  lysis  after  the  second  or  third  dose,  and 
the  pulse  becomes  normal  two  or  three  days  after  the  temperature  has 
fallen.  The  irregularities  of  the  pulse  are  not  so  fi'equent  in  diphtheria 
since  the  antitoxin  treatment  has  been  employed. 

Antitoxin  does  not  seem  to  destroy  the  bacilli  in  diphtheria,  but  to 
have  some  special  action  on  the  tissue-cells.  If  the  cells  have  been  much 
damaged  they  do  not  respond,  and  this  is  an  argument  in  favor  of  the 
early  administration  of  antitoxin.  The  antitoxin,  however,  is  not  able  to 
combat  complications  referable  to  secondary  infection.  It  is  not  a  fact 
that  since  antitoxin  has  been  used  the  type  of  diphtheria  epidemics  has 
been  less  virulent,  as  has  been  suggested. 

The  pains  which  occur  during  the  course  of  diphtheria  are  probably 
forms  of  neuritis,  and  not  the  result  of  the  antitoxin  which  has  bsen 
given.  The  later  forms  of  neuritis  which  occur  two  or  three  months  after 
the  disease  has  run  its  course  have  nothing  to  do  vnih  the  administration 
of  antitoxin.  The  arthralgia  and  efflorescences  which  occur  during  the 
disease  may  arise  from  the  antitoxin,  but  are  never  serious,  and,  although 
the  number  of  cases  of  neuritis  arising  in  the  course  of  diphtheria  since 
the  use  of  antitoxin  is  greater  than  before  its  use,  they  are  rarely  of  a 
severe  type,  and  seldom  need  cause  any  great  amount  of  anxiety.  Out 
of  one  million  cases  in  which  injections  of  antitoxin  were  given,  only  five 
deaths  were  reported  which  could  be  attributed  to  the  effects  of  the  anti- 
toxin. 

30 


466 


PEDIATRICS. 


Albuminuria  is  one  of  the  most  constant  symptoms  of  diphtheria. 
McCollom  had  the  urine  tested  in  two  hundred  cases  before  the  adminis- 
tration of  antitoxin,  and  in  only  ten  cases  was  the  amount  of  albumin  in- 
creased after  the  administration  of  antitoxin,  and  these  ten  cases  were  of 
a  severe  type.  There  was  no  reason  to  suppose  that  the  antitoxin  had 
anything  to  do  with  the  increase  in  the  albumin.  It  is  to  be  noted  that, 
according  to  Baginsky's  observations,  nephritis  may  occur  in  mild  cases 
of  diphtheria  as  well  as  in  severe  cases. 

Antitoxin  has  no  influence  in  preventing  the  later  symptoms  of 
paralysis  and  cardiac  failure,  excepting  as  a  prophylactic  when  it  is  given 

early. 

When  there  is  a  concurrent  infection  the  antitoxin  serum  is  less  effec- 
tual, as  it  does  not  counteract  the  toxin  absorption  due  to  bacteria  other 
than  the  Klebs-Loeffler  bacillus.  It  is  not  safe  to  assume,  however,  that 
there  is  a  concurrent  affection  because  other  bacteria  are  found  in  the 
throat.  When  the  larynx  is  involved,  with  accompanying  stenosis,  the 
antitoxin  serum  is  found  to  be  very  valuable,  and  has  reduced  the  number 
of  operative  cases.  The  antitoxin  has  been  found  to  have  but  little  effect 
upon  the  length  of  time  which  the  bacteria  remain  in  the  throat  after  the 
disappearance  of  the  membrane. 

Antitoxin  should  be  freely  used  in  diphtheria  of  the  eye.  The  pupils 
should  be  dilated  with  atropine,  and  the  eye  irrigated  with  a  2  to  4  per 
cent,  solution  of  boric  acid.  The  child,  as  soon  as  possible,  should  be 
placed  in  the  hands  of  a  skilled  oculist. 

At  the  South  Department  of  the  Boston  City  Hospital,  in  15,000  cases, 
all  of  which  had  on  an  average  at  least  two  injections  of  antitoxin,  no 
bad  results  were  reported,  and  one  patient  had  52,000  units  of  antitoxin 
given  to  her  and  was  discharged  well. 

In  connection  with  the  antitoxin  treatment  no  especial  drugs  given 
internally  by  the  mouth  are  indicated.  Of  course,  symptomatic  treatment 
of  any  kind  is  not  contra-indicated. 

Technique  of  Antitoxin  Injection. — A  sterilized  glass  syringe  should  be 
employed,  and  the  needle  should  be  comparatively  small.  The  part 
to  be  injected  should  be  thoroughly  sterilized  with  corrosive  sublimate. 
The  anterior  surfaces  of  the  thigh  or  the  lateral  surfaces  of  the  buttocks 
are  convenient  sites  for  injecting  the  antitoxin.  A  needle  previously 
sterilized  by  boiling  should  be  plunged  into  the  tissues  and  the  injection 
made  slowly.  It  is  a  wise  precaution  to  use  a  short  piece  of  a  sterile 
rubber  tubing  to  connect  the  needle  with  the  syringe  in  order  to  lessen 
the  danger  of  having  the  needle  broken  by  the  struggles  of  the  patient. 
The  place  of  puncture  should  then  be  closed  with  sterilized  gauze  and 
collodion. 

Local  Treatment. — The  local  treatment  of  diphtheria  consists  in  thor- 
ough cleansing  of  the  mouth  and,  in  rare  and  unusually  excessive  obstruc- 
tion, of  the  nasal  passages  with  warm  non-irritating  solutions,  such  as 


SPECIFIC    IXFECTIOUS   DISEASES.  467 

normal  salt  solution  or  boracic  acid  4  per  cent.  All  strong  and  irritating 
applications  to  the  throat  in  diphtheria  are  harmful. 

In  the  South  Department  of  the  Boston  City  Hospital  irrigation  of  the 
throat  is  the  routine  treatment,  and  only  in  special  cases  is  irrigation 
through  the  nose  indicated.  This  is  in  order  to  avoid  the  passage  of 
fluid  infected  by  bacteria  into  the  nasal  end  of  the  Eustacliian  tube,  which 
might  produce  infection  of  the  ear. 

Considerable  sutfering  is  at  times  occasioned  by  the  enlargement  of  the 
cervical  glands.  These  are  best  treated  with  flaxseed  or  ice  poultices. 
The  former,  however,  has  a  tendency  to  produce  suppuration,  and  the 
latter  in  most  cases  is  the  best. 

When  it  is  deemed  advisable  to  use  inhalations  of  vapors  in  stenosis 
of  the  lar}Tix  the  following  method  may  be  employed,  but  it  must  be  re- 
membered that  the  child  should  not  be  kept  in  this  atmosphere  continu- 
ously, and  should  be  watched  carefully  to  see  if  it  is  speedily  relieved  of 
the  stenosis  ;  for  if  it  is  not,  the  continuous  inhalation  of  steam  in  the 
comparatively  small  area  of  breatliing-space  which  exists  in  the  tent  that 
is  used  for  this  purpose  may  of  itself  be  detrimental  to  the  child's  re- 
covery, from  lack  of  sufficient  oxygen.  When  tracheotomy  has  been 
performed  an  atmosphere  of  steam  is  especially  valuable.  Dr.  McCol- 
lom's  experience  at  the  South  Department  of  the  City  Hospital  is  that 
the  tent  need  never  be  used,  and  that  it  is  better  to  intubate  at  once. 

The  tent,  as  described  by  Dr.  Xorthrup,  Avho  has  used  it  so  extensively 
ill  the  AVillard-Parker  Hospital  in  New  York,  contains  alDout  fifl^  cnbic 
feet  of  air.  To  extemporize  a  tent,  a  sheet  is  thrown  over  supports 
above  the  crilD  and  allowed  to  fall  over  the  four  sides  of  the  crib.  The 
main  point  is  to  have  a  fairly  large  and  tight  enclosure.  The  apparatus 
for  furnishmg  the  steam  must  be  free  from  the  danger  of  upsetting  and  of 
setting  the  tent  on  fire.  When  there  is  a  mild  form  of  laryngeal  stenosis, 
steam  should  be  only  moderately  used,  as  the  debility  folloAving  a  steam- 
bath  is  often  great.  Sometimes  the  steam  will  give  more  relief  when  it  is 
medicated,  but  this  is  now  considered  very  doubtful. 

Operative  Treatment:  Intubation;  Tracheotomy. — "W-lien  the  antitoxin 
does  not  relieve  the  symptoms  of  stenosis,  and  when  the  progressive 
dyspnoea  is  not  quickly  controlled  by  steam,  it  is  well  not  to  delay  opera- 
tive interference.  In  laryngeal  stenosis  operative  interference  is  de- 
manded by  intubation  or  tracheotomy.  The  indications  are  marked 
supra-clavicular,  sub-sternal,  and  lateral  thoracic  retractions  lastmg  for 
two  or  three  hours  and  apparently  increasmg  in  severity,  a  cyanotic  hue 
of  the  skin,  either  with  or  Avithout  such  retraction,  great  restlessness,  dila- 
tation of  the  alte  nasi,  and  failure  of  strength,  even  if  the  other  symptoms 
are  not  increasing  or  are  absent. 

The  following  is  the  technique  of  intuljation  :  The  patient  is  wrapped 
firmly  in  a  blanket,  so  that  he  cannot  move  his  arms,  and  then  placed  in 
a  horizontal  position,  "v^ith  the  head  slightly  raised.     The  mouth  is  held 


468  ^  .PEDIATRICS. 

open  by  the  gag,  with  its  jaws  resting  on  the  molar  teeth.  The  gag 
should  be  on  the  left  side.  Care  must  be  taken  not  to  have  the  cheek 
injured  by  the  gag,  and  special  pains  must  be  taken  to  prevent  its  slipping. 
The  head  should  be  steadied  by  the  assistant  who  holds  the  gag-.  The 
operator  takes  the  introducer  in  the  right  hand,  with  the  index-fmger 
around  the  hook  on  the  under  surface  of  the  handle,  the  loop  of  silk 
passing  over  his  little  fmger,  and  his  thumb  resting  on  the  button  on  the 
upper  surface  of  the  handle.  The  index-fmger  of  the  left  hand  is  then 
passed  down  to  the  epiglottis,  which  is  hooked  forward ;  the  tube  is  then 
passed  into  the  mouth,  with  the  handle  well  down  on  the  chest  of  the 
patient ;  when  the  epiglottis  is  reached  by  the  point  of  the  tube,  the 
handle  should  be  given  an  abrupt  turn,  so  as  to  bring  the  tube  into  a 
vertical  position.  As  soon  as  the  tube  is  well  in  the  larynx,  the  button 
on  the  handle  should  be  pushed  forward,  disengaging  the  obturator,  wliich 
must  now  be  removed,  and  the  tube  pushed  into  position  by  the  index- 
fmger.  The  loop  of  silk  is  passed  about  the  ear  and  the  gag-  removed. 
If  the  tube  is  in  the  larynx,  the  patient  will  immediately  begin  to  cough 
with  a  jjeculiar  sound,  which,  to  be  appreciated,  must  be  heard.  If  the 
breathmg  becomes  easier,  if  the  cyanotic  hue  disappears,  if  the  retraction 
of  the  thoracic  walls  diminishes,  if  the  loop  of  silk  does  not  shorten,  we 
may  be  assured  that  the  tube  is  in  the  larynx. 

After  becoming  satisfied  that  the  operation  has  been  properly  per- 
formed, the  gag  is  inserted  a  second  time,  the  index-fmger  placed  on  the 
head  of  the  tube,  and  one  strand  of  the  silk  loop  cut,  so  that  it  can  be 
removed.  It  should  be  especially  emphasized  that  the  fmger  of  the  oper- 
ator must  be  a  continuation  of  the  posterior  wall  of  the  larynx,  that  the 
turn  should  be  abrupt,  and  that  no  force  must  be  used.  If  the  tube  is  in 
the  oesophagus,  no  cough  will  be  heard ;  there  will  be  no  relief  in  the 
breathing ;  the  silk  loop  will  commence  to  shorten  as  the  tube  passes 
downward. 

In  certain  instances  intubation  does  not  give  relief,  and  tracheotomy 
must  be  done.  If  the  tube  becomes  clogged  by  membrane,  as  is  some- 
times the  case,  it  must  be  immediately  removed.  The  first  steps  of  an 
extraction  are  similar  to  those  of  an  introduction.  The  extractor  is  passed 
into  the  lumen  of  the  tube  and  the  lever  on  the  handle  pressed  so  as  to 
open  the  jaws,  and  the  tube  extracted  by  a  reverse  of  the  movements  in 
introduction.  Sometimes  there  is  considerable  difficulty  in  extraction,  but 
by  patience  and  gentleness  the  end  can  be  accomplished.  If  the  child 
coughs  up  and  then  swallows  the  tube,  the  accident  may  cause  consider- 
able annoyance  to  the  physician,  yet  it  is  not  of  serious  import,  for  experi- 
ence has  shown  that  the  tube  is  passed  by  the  rectum  in  from  twenty-four 
to  forty-eight  hours,  without  causing  discomfort.  No  definite  rule  can  be 
given  regarding  the  length  of  time  that  the  patient  should  wear  the  tube.- 
It  is  well  to  remove  it  at  the  end  of  the  third  or  fourth  day,  but  it  is  fre- 
quently necessary  immediately  to  reinsert  it.     In  some  instances  three  or 


SPECIFIC   INFECTIOUS   DISEASES.  4(39 

four  extractions  and  introductions  may  be  required.  The  must  favorable 
cases  are  those  in  which  the  child  coughs  up  the  tube  at  the  end  of  the 
third  day,  and  does  not  require  reintubation.  Pielief  should  come  in  flTc 
minutes.  A  child  wliich  has  been  intubated  needs  more  careful  watch- 
ing than  one  in  whom  tracheotomy  has  been  performed,  as  the  acci- 
dents following  intubation  occiu"  more  suddenly  and  are  more  difficult  for 
a  nurse  to  meet. 

O'Dwy^er's  tubes  are  preferably  used  at  the  South  Department  for  the 
pur}30se  of  intubation. 

Tracheotomy  should  be  performed  if,  after  mtubation.  relief  of  the 
breathing  does  not  come  even  when  the  tulje  has  been  removed  and  re- 
placed again.  It  is  extremely  rare  for  tracheotomy  to  succeed  when  in- 
tubation has  failed. 

Feeding. — After  intubation  the  administration  of  food  is  often  diffi- 
cult, and  various  methods  can  be  employed.  (Esophageal  feeding  is  the 
safest  way  of  administering  food,  and  is  one  of  the  unportant  points  to 
be  remembered  when  intubation  has  been  performed,  but,  as  has  already 
been  mentioned,  in  nasal  feeding  there  is  considerable  clanger  of  producing 
irritation  in  the  middle  ear,  not  always,  however,  from  the  Klebs-Loeffler 
bacillus.  The  method  of  feeding  with  the  head  lowered  (Casselberry)  is 
not  devoid  of  danger,  from  the  possibility  of  inhalation  pneumonia  follow- 
ing inspired  particles  of  food.  Nutritive  enemata  of  peptonized  milk,  with 
stimulants,  may,  when  retained,  be  an  important  adjunct  to  the  treatment. 
■  Enemata,  however,  are  not  often  retained.  Digitalis  \n  the  enemata  may 
be  used  in  cases  in  which  heart  failure  is  present. 

Treatment  of  Sequela:.  In  the  treatment  of  post-diphtheritic  paralysis 
strjx-hnine  is  the  most  valuable  drug.  When  there  is  marked  palatal 
paralysis  oesophageal  feeding  is  exceedmgly  imporiant.  Electricity,  espe- 
cially faradism,  is  also  indicated.  Secondaiy  antemia  should  be  treated 
in  the  usual  way,  with  iron,  a  carefully  regulated  diet,  and  by  general 
hygiene. 

INFLUENZA  (LA  GRIPPE). 

Etiology. — Influenza  is  an  acute,  liighly  mfectious  disease.  According 
to  Leichtenstern,  there  are  two  forms  of  influenza.  One  form,  which  is 
known  as  epidemic  influenza,  is  a  pandemic  disease,  caused  by  Pfeiffer's 
bacillus,  and  characterized  by  great  rapidity  of  extension,  varying  symp- 
toms, a  special  tendency  to  attack  the  respiratory  mucous  membranes, 
an  acute  onset,  a  high  degree  of  infection,  and  a  tendency  to  become 
endemic  during  a  succession  of  years  after  its  first  epidemic  outbreak  in  a 
community. 

The  second  form  is  the  common  endemic  or  pseudo-influenza,  or  catar- 
rhal fever,  the  etiology  of  which  is  unknown. 

IxcuBATiox. — The  period  of  incubation  is  short,  being  usually  under 
four  days.     One  attack  does  not  protect  from  another. 


470  PEDIATRICS. 

Symptoms.' — ^The  onset  of  influenza  is  usually  very  acute,  and  the 
symptoms  are  variable.  At  times  they  are  the  same  in  children  as  in 
adults,  but  in  infants  and  young  children  the  symptoms  are  often  not  so 
severe  as  in  the  adult,  although  they  vary  in  different  epidemics.  It  is  a 
characteristic  of  epidemic  influenza  that  it  has  no  distinct  group  of  symp- 
toms of  its  own.  The  symptoms  are  chiefly  a  catarrhal  affection  of  the 
nose  and  throat,  and  frequently  of  the  bronchi.  These  symptoms  in  young 
children  are  accompanied  evidently  by  great  discomfort,  at  times  amount^ 
ing  to  pain,  in  the  limbs  and  body,  although  on  account  of  the  age  of  the 
patient  it  is  impossible  to  determine  whether  much  pam  is  present. 
Sometimes  the  only  marked  symptom  is  a  heightened  and  irregular  tem- 
perature, with  marked  apathy,  and  the  disease  may  be  so  slight  as  to  be 
recognizable  only  during  an  epidemic.  In  older  children  the  symptoms, 
although,  as  a'  rule,  not  of  so  severe  a  type  as  in  adults,  are  at  times  quite 
serious,  especially  if  continuous  vomiting  occurs.  Severe  headache  and 
delirium  are  present  in  some  cases,  and  extreme  emaciation,  out  of  pro- 
portion to  the  fever  or  to  the  morbid  conditions  detectable  on  physical 
examination.  Severe  symptoms  connected  with  the  larynx  and  the 
lungs  may  also  arise  and  rapidly  disappear. 

In  young  infants,  even  when  no  complications  arise,  the  apathy  and 
prostration  may  become  extreme,  and  death  take  place  seemingly  from 
the  overwhelming  intensity  of  the  infection. 

In  addition  to  the  complications  already  mentioned,  various  forms  of 
efflorescences  may  appear  on  the  skin  and  render  the  diagnosis  more  diffi- 
cult. There  is  a  tendency  to  the  development  of  tuberculosis  after  influ- 
enza. Relapses  and  recurrent  attacks  are  not  uncommon,  and  it  should 
be  remembered  that  a  reinfection  at  tmies  seems  to  take  place  in  the  sick- 
room. Out  of  a  large  number  of  cases  in  children  examined  by  Schloss- 
mann, albuminuria  occurred  in  eight  per  cent.,  but  nephritis  was  rare. 
Aucemia  is  a  common  sequela  in  young  children.  Leucocytosis  in  un- 
complicated influenza  is  not  present.  The  mental  disturbances  so  com- 
mon in  adults  and  multiple  neuritis  are  not  marked  sequelae  in  cliildren. 

Variations  ix  Type  of  the  Disease. — It  is  now  generally  recognized 
that  there  are  distinct  types  of  the  disease. 

Respiratory  Type. — In  this,  the  most  common  form  of  the  disease, 
the  influenza  bacillus  may  attack  any  part  of  the  respiratory  tract  from 
the  nose  to  the  pulmonary  alveoli,  the  symptoms  increasing  in  severity 
according  as  the  latter  are  approached.  In  the  milder  forms  there  are  the 
usual  symptoms  of  acute  coryza,  fever,  and  headache,  but  these  sjmiptoms 
are  accompanied  by  a  far  greater  degree  of  prostration  than  is  met  ^Aith 
in  the  ordinary  attacks  of  catarrhal  rhinitis.  These  milder  cases,  without 
complications,  may  last  only  a  few  days  ;  the  temperature  is  usually  mod- 
erate 38.2°  to  39.4°  C.  (101°  to  103°  F.),  but  the  prostration  is  marked. 
An  annoying,  persistent  cough  is  commonly  present. 

This  form  is  sometimes  much  intensified,  may  last  longer,  have  a 


SPECIFIC   INFECTIOUS   DISEASES.  471 

higher  temperature,  and  show  a  greater  tendency  to  comphcations,  espe- 
cially in  the  development  of  otitis  media  and  cervical  adenitis. 

In  another  set  of  cases  of  the  pulmonary  type,  the  disease,  instead  of 
retrograding  steadily,  progresses,  bronchitis  develops,  and  the  accompany- 
ing delirium  and  extreme  prostration  may  simulate  typhoid.  This  bron- 
chitis has  no  especial  peculiarities,  but  in  young  children  it  assumes  at 
times  a  very  intense  grade,  reaching  the  finer  bronchi  and  producing 
cyanosis  and  asphyxia. 

In  certain  instances  an  influenza  pneumonia  develops,  depending 
either  on  the  Pfeiffer's  bacillus  or  on  a  mixed  infection.  This  pneumonia 
is  usually  lobular,  although  rarely  lobar.  Generally,  there  are  small  areas 
of  broncho-pneumonia  diffusely  scattered,  and  often  givmg  rise  to  no  other 
physical  signs  than  scattered  moist  rales.  The  sputum  in  these  cases  of 
influenza  broncho-pneumonia  is  never  "rusty,"  but  is  muco-purulent 
and  generally  of  a  greenish-yellow  color.  A  diagnosis  can  be  made  by 
finding  the  influenza  bacilli  in  large  numbers  within  the  polynuclear  leuco- 
cytes. The  resolution  of  such  a  pneumonia  is  prolonged,  ending  by  lysis. 
This  class  of  cases  is  verj'-  serious,  and  much  of  the  mortality  of  epidemic 
influenza  arises  from  these  pulmonary  complications.  The  broncho-pneu- 
monia is  of  the  ordinar}^  t}^e,  although  possibly  more  irregular  than  in 
other  cases. 

Pleuritis  may  occur  in  the  coiu-se  of  influenza,  but  is  rather  rare ; 
when  present,  however,  it  is  apt  to  become  an  empyema. 

Nervous  Type, — In  certain  cases  there  may  be  no  catarrhal  symptoms 
but  nen^'ous  symptoms  of  the  most  varied  forms.  Pains  in  all  parts  of  the 
body  and  limbs,  cerebral  symptoms  simulating  meningitis,  convulsions, 
delirium,  opisthotonos,  symptoms  simulating  pneumonia  without,  however, 
the  physical  signs  of  that  disease,  or  a  typhoid  condition  with  weak,  rapid 
pulse,  a  temperature  of  40.5°  to  41.1°  C.  (105°  to  106°  F.),  and  irregu- 
larity of  the  heart.  All  these  severe  and  alarmmg  symptoms  may  pass  off 
in  two  or  three  days  and  leave  no  trace  of  any  of  the  simulated  diseases, 
although  the  resulting  prostration  may  last  for  a  long  period. 

Gastro-Enteric  Type. — In  this  form  of  the  disease  the  prominent 
symptoms  are  nausea,  vomiting,  abdominal  pain,  diarrhoea,  and  a  ten- 
dency to  collapse. 

The  spleen  is  enlarged  in  a  certain  number  of  cases,  and  this,  according 
to  Osier,  depends  on  the  intensity  of  the  fever.  These  symptoms  may  last 
only  two  or  three  days,  and,  as  a  rule,  are  not  followed  by  an  unfavora- 
ble result. 

Febrile  Type, — The  temperature  in  mfluenza  is  very  variable,  and,  as 
stated  by  Osier,  may,  with  its  accompanying  prostration,  be  the  only 
manifestation  of  the  disease. 

It  may  be  remittent  and  associated  with  chills,  or,  on  the  other  hand, 
may  be  of  a  continued  type,  and  so  prolonged  as  to  simulate  typhoid  fever. 

Diagnosis. — ^The  diagnosis  of  epidemic  influenza  is  often  difficult,  un- 


472  PEDIATRICS. 

less  influenza  is  present  in  the  community,  and  is  to  be  made  by  the  care- 
ful elimmation  of  other  diseases,  and  the  detection  of  Pfeiffer's  bacillus, 
either  in  the  secretions  of  the  nose  or  in  the  sputum.  The  profound 
prostration  out  of  proportion  to  the  intensity  of  the  disease  is  of  great 
diagnostic  value.  In  the  early  days  of  the  disease  it  is  often  impossible 
to  differentiate  from  pneumonia,  malaria,  the  acute  exanthemata,  and 
meningitis,  but  later  the  differential  diagnosis  is  made  by  the  disappear- 
ance of  the  especial  symptoms  of  these  diseases,  and  the  failure  to  find 
their  special  infecting  organisms.  The  diazo-reaction  is  absent  in  influ- 
enza. 

Prognosis, — The  disease  in  itself  is  not  dangerous,  but  complications 
are  especially  liable  to  arise  and  make  the  prognosis  much  more  serious. 
These  complications  are  very  numerous.  They  may  be  meningitis,  otitis, 
ileo-colitis,  broncho-pneumonia,  and  lobar  pneumonia.  The  most  com- 
mon and  dangerous  complication  of  influenza  is  pneumonia,  which  is 
usually  a  broncho-pneumonia,  and  is  of  serious  import,  especially  if  the 
child  is  debilitated  at  the  time  of  the  attack  by  some  previous  disease. 
The  broncho-pneumonia  of  influenza  is  of  more  serious  import  than  that 
arising  from  other  causes,  with  the  exception  of  infections  due  to  tuber- 
culosis  or  diphtheria. 

Treatment. — In  the  treatment  of  epidemic  influenza  in  infants  and 
children,  small  doses  of  phenacetine  or  antipyrin,  0.06  gramme  (I  grain), 
once  in  three  or  four  hours,  with  ten  or  fifteen  drops  of  brandy,  seem  to 
yield  as  good  results  as  any  other  mode  of  treatment.  Many  of  the  other 
derivatives  of  coal-tar  and  salicylic  acid  we  have  used  with  much  relief  of 
symptoms,  AVhen  there  is  severe  and  continuous  vomiting,  small  doses 
of  iced  champagne  by  the  mouth,  enemata  of  bromide  of  potassium,  and, 
if  necessary,  hydrate  of  chloral,  are  indicated.  The  child  should  be  kept 
in  bed  and  isolated.  The  bronchial  and  nasal  secretions  should  be  disin- 
fected. Stimulants  are  especially  indicated  when  pneumonia  is  present, 
and  str}'"chnine  is  valuable  as  a  heart  stimulant.  A  high  temperature,  ner- 
vous and  gastro-enteric  symptoms,  should  receive  the  appropriate  treatment 
as  in  other  diseases.  When  the  convalescence  is  prolonged,  especially  if 
the  case  has  been  one  of  the  pulmonary  type,  or  when  there  is  a  tendency 
to  tuberculosis  or  to  a  recurrence  of  the  attack,  a  change  of  climate  is 
decidedly  indicated  and  is  frequently  beneficial.  The  diet  should  be  milk 
and  beef  tea.  Careful  feeding  is  very  important  after  an  attack  of  influenza, 
as  there  is  often  left  a  tendency  to  infantile  atrophy. 

During  the  epidemic  of  influenza  which  occurred  in  Boston  in  1891,  we 
had  under  our  care  at  the  Infants'  Hospital  seven  infants,  varying  in  age 
from  a  few  months  to  one  and  a  half  years,  all  of  whom  had  epidemic 
influenza.  Pneumonia  occurred  in  two  of  the  cases,  and  in  both  of  these 
the  infants  died.  The  following  charts  (Charts  13  and  14)  show  the  tem- 
perature of  these  cases  during  the  course  of  the  disease,  and  the  rise 
when  the  infants  were  attacked  with  pneumonia. 


SPECIFIC   INFECTIOUS   DISEASES. 
CHAKTS  13  and  14. 


473 


Influenza. 

Pneumonia.     ^^^V^l 

y  Disease,„fl^^„^^ 

Pneumonia. 

F. 

1 

2 

3 

4 

6 

1 

2 

3 

C 

107° 
106° 
105° 
104° 
103 
102 
101° 
100° 
99 

NORMAL 
TEMP. 

98 
97° 

96 
95 

H  E 

M  E 

M  E 

M  E 

M  E 

ME 

ME 

M  E 

M  E 

M  £ 

ME 

ME 

M  E 

ME 

ME 

ME 

ME 

M  E 

M  £ 

M  E 

ME 

41.6° 
41  1  ° 

■c 

" 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7* 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 

j 

f 

/ 

//U 

1 

,, 

/ 

/ 

/ 

y 

/ 

/ 

V 

y 

/ 

^ 

1 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

^ 

1 

r 

Infantile  atrophy.    Epidemic  influenza. 
Pneumonia.    Male,  4  months  old. 

Previously  healthy.    Epidemic  influenza. 
Pneumonia.    Female,  3  months  old. 

CHART  15. 

Influenza 

Days  of  Disease    p„eumonia 

F. 

8 

4 

5 

6 

7 

8 

9 

10 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

C. 

107° 
106 
105 
104 
103 
102 
101 
lOO 
99 

><ORMAI 
TEMPo 

98 
97° 
96° 
95° 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  £ 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36.1° 

35.5° 

35.0° 

f 

i 

/ 

1 

/ 

/ 

V 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

f 

/ 

/ 

k 

y 

^ 

y 

\ 

\ 

y 

y 

u 

:= 

Epidemic  influenza.    Pneumonia.    Recovery.    Male,  16  months  old. 

Another  case  of  influenza  was  complicated  on  the  eleventh  day  of  the 
disease  by  a  lobar  pneumonia. 

The  infant,  sixteen  months  old,  was  attacked  with  catarrhal  symptoms  of  the  nose 
and  throat,  a  slight  cough,  and  a  temperature  of  40.5°  C.  (105°  F.).  The  respira- 
tions were  only  slightly  increased  ;  the  pulse  was  rapid.  Nothing  abnormal  was  found 
on  physical  examination.     The  infant  was  very  fretful,  had  no  appetite,  cried  inces> 


474 


PEDIATRICS. 


santly,  and  seemed  to  have  considerable  discomfort.  On  the  ninth  day  from  the  onset 
of  the  attack  the  temperature  fell  to  39.1°  C.  (102,5°  F.),  and  on  the  following  day  to 
38.6°  C.  (101.5°  F.).  On  the  evening  of  this  day  the  infant,  who  had  begun  to  be 
brighter  and  to  notice  its  playthings,  again  seemed  very  sick.  Its  respirations  in- 
creased in  frequency,  there  was  motion  of  the  alae  nasi,  and  the  temperature  rose  to 
40.8°  C.  (105.4°  F.).  On  the  following  day  the  temperature  fell  in  the  morning,  but 
began  to  rise  in  the  evening,  and  by  the  next  day  had  reached  41.0°  C.  (105.8°  F.). 
On  this  day,  the  thirteenth  from  the  beginning  of  the  attack  and  the  third  from  the 
fresh  invasion,  marked  flatness  was  detected  in  the  right  lower  back,  with  bron- 
chial Respiration  and  increased  tactile  and  vocal  fremitus.  This  area  of  flatness  in- 
creased, and  finally  involved  the  whole  lower  lobe  of  the  right  lung.  On  the  fourth 
day  of  this  new  invasion  the  temperature  fell  to  38.8°  C.  (102°  F.)  ;  on  the  following 
day  it  rose  to  39.7  C.  (103.5°  F.)  in  the  evening,  and  in  the  next  two  days  gradually 
fell  to  37i2°  C.  (99°  F.).  On  the  following  day  it  rose  to  38.6°  C.  (101.5°  F.),  and 
in  the  next  forty-eight  hours  fell  gradually  to  36.6°  C.  (98°  F.).  At  this  time  the 
dulness  began  to  disappear,  moist  rales  appeared,  the  infant  became  much  better,  and 
in  a  few  days,  although  very  weak,  seemed  bright  and  well,  and  the  physical  signs  in 
the  lung  had  entirely  disappeared. 

Chart  15  shows  the  temperature  during  ten  days  of  the  influenza,  when  a  lobar 
pneumonia  appeared  and  ran  a  course  of  five  days,  after  which  the  temperature  gradu- 
ally fell  to  the  normal  point.  It  is  possible  thutthis  case  was  one  of  pneumonia  from 
the  beginning  of  the  attack,  but  it  showed  all  the  characteristic  symptoms  of  epidemic 
influenza,  and  no  flatness  was  found  in  the  lung  until  the  infant  had  apparently  re- 
covered from  its  influenza. 


MALARIA. 

Malaria  is  an  infectious  disease,  transmitted  from  an  infected  human 
being  by  means  of  mosquitoes  of  the  genus  anopheles  to  another  human 
being.     There  may  be  other  sources  of  infection  not  yet  determined. 

Etiology. — The  specific  infection  of  malaria  is  primarily  shown  in  the 
blood  in  the  form  of  certain  micro-organisms  which,  like  the  amoeba  coli, 
belong  to  the  class  of  protozoa  and  inhabit  the  J^lood  of  the  infected  indi- 
vidual. The  micro-organism  of  malaria  has  not  been  found  in  any  part 
of  the  body  except  in  the  blood  and  within  the  blood-vessels,  and  malaria 
may  therefore  justly  be  said  to  be  a  disease  of  the  blood. 

The  Avork  of  Ross,  Grassi,  Bignami,  Bastianelli,  Daniels,  and  Koch  has 
shown  that  the  most  important  and  very  probably  the  only  manner  of 
infection  in  malarial  fever  is  through  the  bites  of  mosquitoes  of  the  genus 
anopheles,  which,  with  man,  form  the  regular  hosts  of  the  parasite.  The 
malarial  parasite,  like  the  coccidia,  has  been  shown  to  possess  both  an 
asexual  and  a  sexual  cycle.  The  sexual  cycle  takes  place  in  the  human 
body  and  ends  in  segmentation,  each  segment  attacking  a  new  red  cor- 
puscle, and  beginning  again  a  new  cycle  as  a  fresh  young  parasite.  Cer- 
tain bodies,  however,  when  they  reach  full  development,  do  not  undergo 
segmentation.  These  are  the  large,  full-grown,  sometimes  wrongly  called 
"extra-cellular  bodies"  of  the  tertian  and  quartan  parasites,  and  the 
crescentic  and  ovoid  forms  of  the  sestivo-autumnal  parasite.  When  a 
mosquito  of  the  genus  anopheles  bites  an  infected  human  being,  certain 


SPECIFIC   INFECTIOUS   DISEASES.  475 

of  these  forms,  the  male  elements,  develop  flagella  in  the  stomach  of  the 
mosquito.  The  flagella  attack  and  fecundate  the  female  forms,  which 
penetrate  into  the  muscular  coat  of  the  wall  of  the  mosc|uito's  stomach 
and  there  undergo  development.  After  seven  days  these  bodies,  which 
protrude  from  the  external  wall  of  the  mosquito's  stomach,  rupture,  setting 
free  great  numbers  of  small  spindle-shaped  structures,  which  accumulate  in 
the  veneno-salivary  glands  of  the  mosquito.  When  such  a  mosquito  bites 
again,  these  bodies  are  introduced.  Each  one  of  these  is  equivalent  to 
one  of  the  segments  of  the  asexual  cycle,  and  is  ready  to  attack  a  new 
red  blood-corpuscle  and  pursue  a  similar  cycle. 

In  this  country  there  exist  several  varieties  of  anopheles,  one  of  which, 
the  anopheles  quadrimaculatus^  has  been  shown  by  Thayer  and  Wooley  to 
act  as  an  intermediate  host  for  the  parasite.  It  is  not  yet  settled  whether 
the  anopheles  can  obtain  the  parasite  from  other  sources  than  from  man, 
although  it  seems  probable  that  this  is  not  the  case. 

The  facts  which  so  far  have  been  accumulated  in  Italy  and  in  this 
country  appear  to  show  that  the  first  cases  in  the  spring  and  early 
summer  are  relapses.  With  the  appearance  of  mosquitoes  of  the  genus 
anopheles,  which  occurs  probably  in  July  or  August,  according  to  the 
part  of  the  country,  the  spread  of  the  disease  begins,  the  fresh  cases 
arising  as  a  result  of  the  transference  of  the  infection  from  relapses.  The 
disease  gradually  increases  during  the  season  in  which  the  anopheles 
pre\ails,  only  to  diminish  again  with  the  frosts  and  the  disappearance  of 
this  type  of  mosc|uito.  The  ordinary  house  mosquitoes,  which  we  see  in 
most  of  our  cities  and  towns,  excepting  in  the  very  malarious  districts, 
do  not  belong  to  the  harmful  class.  They  belong  to  the  genus  ciUex. 
The  main  differehces  between  the  culex  and  the  anopheles  are  readily 
made  out.  In  the  first  place,  all  the  common  forms  of  culex  which  we 
see  have  wings  free  from  marking,  beyond  the  ordinary  veins.  All  three 
varieties  of  anopheles  positively  known  in  this  country  have  spotted 
wings.  The  most  important  and  simple  distinction,  however,  is  the 
manner  in  which  these  varieties  of  mosquitoes  sit  on  the  wall.  The 
culex  sits  on  the  wall  with  its  body  parallel  to  the  surface  to  which  it  is 
attached  and  the  posterior  pair  of  legs  raised  over  its  back.  The  anoph- 
eles, on  the  other  hand,  sits  with  its  body  sticking  out  from  the  wall  at  an 
angle  of  forty-five  degrees  or  greater,  with  the  posterior  pair  of  legs,  which 
are  very  long,  resting  against  the  wall  or  hanging  down.  When  such  a 
mosquito  is  sitting  on  the  ceiling  he  looks  often  as  if  he  were  hanging 
from  his  proboscis.  This  distinction  is  readily  made  out  by  any  layman. 
The  anopheles  and  culex  are  represented  in  Plate  XV.,  opposite  page  884. 
A  third  point  is  the  difference  of  the  mouth  parts.  The  ordinary  house 
mosquito,  the  culex,  has  a  single  long  proboscis,  at  the  root  of  which  are 
two  little,  short,  stump-like  processes,  the  palpi.  In  the  anopheles  these 
palpi  are  of  a  length  almost  equal  to  the  proboscis,  so  that  on  superficial 
examination  the  mosquito  looks  as  if  he  had  three  proboscides. 


476  PEDIATRICS. 

The  frequency  of  malaria  in  infants  and  young  children,  which  has 
been  recognized  for  a  good  while,  has  been  strikingly  brought  out  by 
Koch's  studies  in  Java.  This  frequency  is  in  all  probability  in  part  due 
to  the  well-known  fact  that  very  young  children  are  especially  subject  to 
mosquito-bites.  A  rather  interesting  point  in  connection  with  this  is  that 
Koch  uses  the  presence  or  absence  of  malaria  in  infants  as  an  index  as 
to  whether  a  district  is  or  is  not  malarious.  In  adults  it  is  always  pos- 
sible that  the  disease  may  have  been  imported.  Infants,  however,  have 
usually  acquired  the  disease  at  home.  The  proportion  of  cases  in  infants 
appears  to  be  greater  than  at  any  other  age.  When,  then,  the  infants 
are  free  from  malaria,  or  occasional  cases  occur  among  adults,  it  is  prob- 
ably safe  to  say  that  the  disease  is  imported. 

The  germs  of  this  parasite  may  be  contained  in  the  blood-plasma,  or 
in  the  substance  of  the  erythrocytes.  The  name  plasmodium  has  been 
given  to  the  germ  found  in  the  red  blood-disks.  According  to  Thompson, 
in  acute  paludism  (malarial  fever)  the  plasmodium  is  found  in  the  form 
of  amoeboid  bodies,  occupying  a  place  in  a  certain  number  of  the  ery- 
throcytes or  adhering  to  them.  These  bodies  derive  pigment  (melanm) 
from  the  erythrocytes,  and,  after  undergoing  a  certam  degree  of  develop- 
ment, increase  in  size  at  the  expense  of  the  erj^throcytes.  They  are  found 
to  contain  this  pigment  in  distinct  granules  and  rods.  They  var)^  in  size, 
and  some  are  as  large  as  the  erythrocytes.  They  are  at  first  colorless 
and  transparent,  and  at  the  height  of  theh  development  they  undergo 
segmentation.  This  amoeboid  form  of  the  parasite  is  the  one  commonly 
found  in  what  is  designated  as  the  tertian  variety  of  malaria,  and  is  the 
most  common  of  all  the  known  forms  of  the  parasite  of  malaria. 

In  addition  to  these  amoeboid  forms,  crescentic  shapes  of  the  germ,  ac- 
cording to  the  investigations  of  Laveran,  are  common  in  the  blood  of  certain 
types  of  paludism,  irregular  forms  of  the  disease,  and  malarial  cachexia. 
Like  the  amoeboid  forms,  they  are  transparent  and  colorless,  except  for 
the  pigment  granules  which  they  contain  in  their  centres.  They  are  larger 
than  the  amoeboid  forms,  are  much  more  rare,  are  much  less  affected 
by   the    action   of   quinine,   and    are    one    form    of  the    cestivo-autumnal 

variety. 

Councilman  describes  flagellate  bodies  as  being  most  commonly  found 
in  blood  which  has  been  aspirated  from  the  spleen  ;  and  in  acute  cases  of 
malaria  they  may  sometimes  appear  in  other  situations.  They  exhibit 
from  three  to  eight  vibrating  cilia. 

It  is  still  a  matter  of  dispute  wiiether  the  plasmodium  malarias  is  poly- 
morphous and  thus  may  produce  the  different  types  of  malaria,  or 
whether  there  are  certain  distinctly  separate  organisms  to  which  the  name 
Plasmodium  malarise  is  applied. 

There  is  no  doubt  that  two  distinct  forms  of  parasites  of  malaria  can 
be  diagnosticated  by  the  appearance  of  the  plasmodium  in  the  blood,  and 
that  these  two  forms  can  be  separated  clinically. 


SPECIFIC   INFECTIOUS   DISEASES.  477 

Golgi  is  the  investigator  who  has  most  clearly  shown  that  there  is 
more  than  one  parasite  of  malaria,  while  Laveran  is  the  exponent  of  the 
polymorphous  theory. 

The  malarial  parasite  may  be  most  simply  and  surely  found  by  exami- 
nation of  a  fresh  unstained  specimen  of  blood.  A  small  drop  of  fresh 
blood  is  placed  on  a  glass  slide  and  covered  with  a  cover-glass,  making  a 
very  thin  layer,  and  examined  with  an  oil-immersion  lens.  The  slide 
and  cover  must  be  perfectly  clean  and  dry.  Dried  and  stained  specimens 
are  only  to  be  used  when  an  examination  of  fresh  blood  is  impossible. 

There  are  definitely  three  varieties  of  the  malarial  parasite,  tertian, 
quartan,  and  cestivo-autumnaL  The  sestivo-autumnal  is  usually  associated 
with  paroxysms  occurring  about  forty-eight  hours  apart ;  these  paroxysms, 
however,  being  considerably  longer  than  those  in  tertian  or  quartan  fever. 
Very  commonly,  however,  owing  to  multiplicity  of  groups  of  parasites, 
the  fever  is  irregular,  remittent,  or  continuous.  The  relation  of  these 
three  varieties  of  malarial  parasites  to  the  periodicity  of  the  disease  is 
shown  in  Table  59,  on  page  479. 

The  tertian  parasite  first  appears  in  the  red  blood-corpuscles  as  small 
hyaline  bodies  with  amoeboid  movements.  It  increases  in  size  and  de- 
velops fine,  dark,  pigment  granules,  which  are  in  constant  motion,  due  to 
the  amoeboid  contractions  of  the  protoplasm  of  the  individual  parasites. 
The  red  cells  which  contain  them  become  slightly  enlarged  and  gradually 
decolorized.  Each  parasite  when  fully  grown  nearly  fills  the  red  corpuscle. 
In  the  stage  of  segmentation,  which  occurs  at  the  time  of  the  paroxysm, 
fifteen  or  twenty  segments  appear,  which  invade  fresh  red  corpuscles,  and 
begin  the  cycle  again  as  hyaline  bodies. 

The  quartan  parasite  resembles  the  tertian,  but  its  amoeboid  move- 
ments are  slower,  the  pigment  granules  are  coarser,  darker,  and  less  active, 
the  full-grown  organism  is  smaller,  and  the  red  cell  in  which  the  organism 
develops  becomes  somewhat  shrunken  about  the  parasite,  and  of  a  deeper, 
old-brass  color.     It  segments  into  only  five  or  ten  parts. 

The  cestivo-autumnal  parasite  is  smaller  than  the  others  and  contains 
less  pigment.  The  corpuscles  containing  them  become  slirunken  and 
brass-colored.  About  a  month  after  the  onset  of  the  attack,  character- 
istic crescentic  or  ovoid  bodies  appear,  which  have  coarse  pigment  granules 
clumped  in  the  centre.  Flagellate  forms  of  the  tertian,  quartan,  and 
sestivo-autumnal  parasites  may  appear.  The  segmentation  of  the  oi^an- 
ism  is  always  coincident  with  the  paroxysms,  and  the  interval  between 
the  paroxysms  is  characterized  by  a  distinct  and  early  stage  of  develop- 
ment of  the  parasites. 

The  tertian  form  is  the  one  which  is  by  far  the  most  common  in  this 
part  of  the  country,  and  the  one  which  is  most  influenced  by  the  admin- 
istration of  quinine,  the  other  form,  represented  by  the  quartan,  being 
pecuharly  difficult  to  manage  with  quinine.  In  young  infants  the  tertian 
form  in  its  quotidian  variety  is  met  with  most  commonly.     In  older  chil- 


478  PEDIATRICS. 

dren,  in  our  experience,  it  is  the  pure  tertian  that  is  most  common.  It 
Avill  be  noticed,  on  examining  the  table  on  page  479,  that  the  quartan 
form  of  paludism  can  never  represent  by  its  intervals  and  paroxysms  the 
pure  tertian  form. 

Pathological  Anatomy. — There  are  no  especial  differences  between  the 
pathological  lesions  found  in  the  malaria  of  children  and  those  which  occur 
in  adults.  According  to  Thayer,  in  acute  cases  of  malarial  fever,  on  exami- 
nation with  the  microscope,  the  cerebral  capillaries  are  found  to  be 
crowded  with  malarial  parasites.  There  is  usually  a  marked  granular  de- 
generation of  the  endothelium  of  the  vessels. 

The  spleen  is  always  enlarged,  often  only  moderately.  The  parenchyma 
is  cyanotic,  of  a  slaty-gray  color,  and  almost  diffluent.  The  pulp  of  the 
spleen  is  found  to  contain  enormous  numbers  of  red  blood-corpuscles, 
many  of  which  contain  parasites.  Great  numbers  of  white  cells  are  also 
seen,  some  of  them  being  necrotic.  The  capillaries  are  usually  filled  with 
red  blood-corpuscles  containing  the  plasmodia,  while  the  splenic  veins 
show  relatively  few,  although  they  always  contain  large  cells  enclosing 
pigment  or  the  remains  of  red  blood-corpuscles. 

The  liver  is  swollen  and  has  usually  a  slaty-gray  color.  The  capilla- 
ries are  filled  with  leucocytes,  which  contain  numerous  pigmented  bodies. 
Relatively  few  plasmodia  are  found  in  the  blood-corpuscles  in  the  vessels. 
Areas  of  disseminated  necrosis  similar  to  those  in  other  acute  infectious 
diseases  have  been  described. 

The  vessels  of  the  kidneys  contain  relatively  few  organisms.  The 
glomeruli  may  be  considerably  pigmented.  There  may  be  marked  de- 
generation of  the  epithelium  of  the  capsule,  and  at  times  changes  in  the 
parenchyma,  especially  areas  of  necrosis  of  the  epithelium  of  the  con- 
voluted tubules.  The  other  viscera  show  no  special  characteristic  changes, 
except,  at  times,  that  of  melanosis. 

Symptoms. — The  symptoms  of  malaria  as  the  disease  occurs  in  infants 
and  young  children  are  much  more  varied  and  far  more  uncertain  than 
those  which  we  are  accustomed  to  meet  with  in  adults.  The  prominent 
symptom  of  malaria  being  the  paroxysm,  earlier  authors  naturally  classi- 
fied malaria  according  to  the  time  when  the  paroxyms  appeared,  using 
the  term  quotidian  when  they  occurred  with  intervals  of  twenty-four 
hours,  tertian  when  they  occurred  with  intervals  of  forty-eight  hours, 
and  quartan  where  they  occurred  with  intervals  of  seventy-two  hours. 
The  term  tertian  is  somewhat  misleading  unless  we  understand  that  it  is 
a  word  derived  from  the  Latin  method  of  counting  the  day  of  the  be- 
ginning of  the  febrile  manifestation  as  the  first  day.  The  terms  tertian 
and  quartan,  therefore,  are  simply  used  empirically  to  represent  intervals 
of  forty-eight  and  of  seventy-two  hours  between  the  paroxysms.  Again, 
the  terms  intermittent  and  remittent  have  been  used  commonly.  The  in- 
termittent form  is  characterized  by  entire  absence  of  fever  between  the 
paroxysms.     The  remittent  form  is  characterized  by  the  presence  of  more 


SPECIFIC   IXFECTIOUS    DISEASES. 


479 


or  less  fever  of  a  continued  type  which  does  not  cease  between  the 
paroxysms.  These  terms  should  not  be  used  as  classifications  of  distinct 
types  of  malaria,  as  the  conditions  which  they  represent  may,  according 
to  chance,  appear  in  any  of  the  types,  and  are  merely  caused  by  a  varia- 
tion in  the  behavior  of  the  parasite.  In  general,  in  children  there  is  a 
tendency  in  all  types  of  malaria  towards  a  deviation  from  the  regular 
arrangement  of  parasites  in  groups,  so  that  even  in  tertian  and  quartan 
fever  the  regularity  of  the  manifestations  appears  to  be  not  quite  so 
striking  as  in  adults. 

Accordmg  to  Koplik,  in  pure  types  of  paludism,  either  tertian  or 
quartan,  one  generation  of  the  Plasmodium  will  be  found  to  predominate. 
In  the  eases  of  tertian  variety,  when  the  paroxysms  are  found  to  be  of 
daily  occurrence,  several  generations  of  parasites,  each  T^ith  a  different 
cycle  of  development,  will  be  found  in  the  blood.  The  same  observation 
will  be  found  to  be  true  when  irregular  types  of  fever  with  the  tertian 
parasite  are  carefully  examined,  and  also,  when  the  blood  in  quartan 
fevers  is  examined.  If  more  than  one  generation  of  parasites  exists  in 
the  blood  in  a  tertian  case,  the  fever  may  become  quotidian,  with  daily 
paroxysms  due  to  the  ripenmg  of  distinct  sets  of.  parasites  on  different 
daySj  each  set  of  parasites  taking  forty-eight  hours  to  mature.  In  like 
manner,  in  cases  of  quartan  fever,  through  the  ripening  of  distinct  sets  of 
parasites  on  different  days,  different  combinations  occur,  according  to  the 
number  of  sets  of  parasites.  Thus,  while  in  the  form  in  which  there  is 
only  one  parasite  the  interv'als  between  the  paroxysms  are  seventy-two 
hours,  in  that  in  which  there  are  two  parasites  there  may  be  an  interval 
between  the  paroxysms  of  only  forty-eight  hours,  and  when  there  are 
three  parasites  there  may  be  an  interval  of  only  twenty-four  hours,  thus 
representing  the  quotidian  chills  described  by  Mannaberg.  The  following 
table  explains  the  different  types  of  paludism  as  they  are  now  understood 
bv  the  most  recent  investigators  : 


TABLE  59. 
The  Principal  Combinations  of  Paroxysms  caused  by  the  Plasmodium,  Malarice. 


Intervals. 

1st  day. 

2d  daj-. 

3d  day. 

4th  day. 

Tertiax. 

Pure  tertian 

48  hours. 

Paroxysm. 

Xo  paroxysm. 

Paroxysm. 

Xo  paroxysm. 

(One  parasite.) 

Double  tertian 

24  hours. 

Paroxysm. 

Paroxysm. 

Paroxysm. 

Paroxysm. 

(Two  parasites. 

Quotidian. ) 

QUABTAN. 

Pure  quartan  

72  hours. 

Paroxysm. 

Xo  paroxysm. 

Xo  paroxysm. 

Paroxysm. 

(One  parasite.) 

Double  quartan  ..... 

48  hours.    Paroxysm. 

Paroxysm. 

Xo  paroxysm. 

Paroxysm. 

(Two  parasites.) 

Triple  quartan 

24  hours. 

Paroxysm. 

Paroxysm. 

Paroxysm. 

Paroxysm. 

(Three  parasites. 

Quotidian. ) 

480  PEDIATRICS. 

The  table  explains  how  the  different  intervals  in  the  paroxysms  are 
caused  by  the  development  of  the  parasite  on  different  days.  It  will 
therefore  be  understood  that  it  is  according  as  the  parasite  happens  to  de- 
velop that  we  have  a  regular  or  an  irregular  periodicity.  Thus,  it  may 
happen  that  we  have  two  parasites,  and  these  two  parasites  may  develop 
on  the  same  day,  but  at  different  hours.  In  this  case,  supposing  that  they 
are  of  the  tertian  type,  two  paroxysms  may  occur  on  the  same  day,  fol- 
lowed by  an  interval  of  forty-eight  hours  from  the  time  of  the  full  de- 
velopment of  each  of  the  parasites  until  this  development  occurs  again. 
In  this  way  different  broods  of  parasites  may  cause  an  almost  infinite 
variety  of  symptoms. 

The  younger  the  individual  the  more  likely  are  the  pronounced  chills 
to  be  replaced  by  some  other  symptom,  such  as  vomiting,  delirium,  and 
convulsions.  The  paroxysms  come  more  frequently  in  children  than  in 
adults  and  in  young  children  a  condition  of  apathy  and  somnolence,  some- 
times \\dth  fever,  and  sometimes  accompanied  by  coldness  of  the  extremi- 
ties and  a  collapsed  condition,  very  commonly  replaces  the  chill  of  the 
adult.  These  symptoms,  representing  the  onset  of  the  disease,  may  often 
disappear  as  the  disease  becomes  established,  and  in  their  place  we  may 
meet  ^^dth  the  symptoms  of  some  other  disease,  such  as  bronchitis,  torti- 
collis, and  many  other  affections.  The  symptoms  of  these  other  diseases 
will  often  continue  and  be  very  intractable  until  quinine  is  given,  when 
they  will  disappear,  and  thus  we  shall  be  led  to  believe  that  we  have  been 
dealing  with  one  of  the  masked  and  misleading  manifestations  of  the  Plas- 
modium malariae,  as  illustrated  by  the  case  described  on  page  483. 

The  susceptibility  of  the  nervous  and  respiratory  systems  in  young 
children  to  produce  variations  in  the  form  and  type  of  malaria  is  most 
misleading  in  regard  to  diagnosis,  the  symptoms  referable  to  a  particular 
organ  often  completely  overshadowing  the  real  disease,  malaria,  and  pro- 
ducing an  entirely  new  clinical  picture.  The  symptoms  often  are  so  indefi- 
nite and  the  disease  frequently  com.es  on  so  insidiously  that  the  physician 
does  not  see  the  case  until  it  has  made  considerable  progress  and  the  diag- 
nosis is  thus  much  obscured. 

In  addition  to  the  other  symptoms,  severe  pain  in  the  head  and  some- 
times in  the  epigastric  region  is  met  with.  In  the  form  in  which  the  in- 
vasion is  gradual,  the  prominent  symptoms  are  anaemia,  loss  of  appetite, 
and  frontal  headache  of  moderate  type.  The  spleen  in  the  majority  of 
cases  is  found  to  be  enlarged.  It  is  possible  that  in  the  cases  in  which 
no  enlai^ement  of  the  spleen  is  demonstrable  it  may  nevertheless  be 
present  without  our  being  able  to  detect  such  enlargement  by  percussion 
or  palpation.  Splenic  and  hepatic  tenderness,  pains  in  the  back,  extremi- 
ties, and  neck,  and  general  cutaneous  hyperaesthesia  are  occasionally 
obser^'ed.  As  the  capsule  of  the  spleen  is  less  resistant  in  young  chil- 
dren than  in  adults,  the  oi^an  seems  to  enlarge  more  rapidly  and  also  to 
subside  more  quickly  in  children. 


SPECIFIC    LXFECTKJUri    DISEASES.  481 

The  time  and  character  of  the  onset  of  the  disease  and  of  its  parox- 
ysms are  very  irregular,  so  much  so,  indeed,  that  it  would  not  be  prac- 
ticable to  dwell  upon  the  exact  differences  which  occur  from  those  in  the 
adult.  In  general,  the  fever  is  relatively  higher,  and  the  sweating  stage  is 
apt  to  be  absent. 

According  to  Holt's  record  of  his  cases  in  New  York,  the  onset  is  acute 
with  vomitmg  and  prostration.  The  temperature  is  high,  rangmg  from 
40°  to  41°  C.  (104  to  106°  F.).  The  respiration  is  feeble  or  harsh  over 
the  back  of  one  or  both  lungs,  sometimes  with  coarse  moist  rales,  and 
usually  a  slight  increase  of  vocal  fremitus  and  slight  dulness  on  percus- 
sion. These  signs  and  symptoms  may  disappear  in  the  course  of  a  few 
hours  with  the  fall  in  temperature,  and  may  recur  on  the  following  days 
until  quinine  is  administered.  Bronchitis  was  found  to  be  the  most  fre- 
quent of  all  the  complications  occurring  in  the  course  of  malaria,  and 
again  and  again  proved  to  be  mtractable  until  its  malarial  origin  was  dis- 
covered. Certain  of  these  acute  cases  appeared  to  be  dependent  upon 
pulmonary  congestions  analogous  m  thtir  pathology  to  the  congestions  of 
the  spleen  and  the  liver.  Pneumonia,  both  lobar  and  lobular,  was  occa- 
sionally found  as  a  complication  of  malaria.  Spasmodic  asthma  of  ma- 
larial origin  Avas  seen  in  some  cases.  These  attacks  were  accompanied 
frequently  l^y  marked  splenic  enlargement,  and  were  promptly  relieved 
by  quinine. 

The  condition  of  the  intestmal  tract  varies  as  much  as  do  the  other 
symptoms.  Sometimes  constipation  is  present  and  sometimes  diarrhoea, 
the  latter  bemg  the  more  prominent  the  younger  the  child. 

Subacute  and  cJtronic  forms  of  malaria  occur  in  children  as  in  adults. 
characterized  by  anaemia,  splenic  enlargement,  a  low  grade  of  fever,  and 
the  presence  of  the  parasites. 

Dl.\gnosis. — ^lalaria  as  it  occurs  in  early  life  is  far  more  difficult  to 
diagnosticate  by  its  symptoms  than  when  the  disease  runs  the  typical 
course  usually  seen  in  the  adult.  It  is  the  most  protean  disease  which 
we  are  called  upon  to  deal  with  in  young  children,  and  it  simulates  so 
closely  so  many  other  conditions  we  are  likely  to  meet  with  that  we 
should  always  be  on  our  guard,  and  allow  the  possil^ility  of  the  existence 
of  the  Plasmodium  malarite  in  makmg  a  diagnosis  in  a  doubtful  case  in 
which  a  periodicity  is  noticed  in  the  symptoms.  The  only  rational 
method  of  determining  whether  Ave  are  dealing  with  a  case  of  malaria  is 
by  an  examination  of  the  blood,  which  at  once  settles  the  question  if  the 
Plasmodium  is  discovered.  The  parasite  can  usually  be  found  in  a  patient 
who  has  had  little  or  no  quinine,  if  the  blood  is  thoroughly  examined 
during  a  paroxysm  by  a  jjerson  who  has  had  considerable  experience. 
The  absence  of  leucocytosis  in  malaria  is  an  unportant  aid  in  the  exclu- 
sion of  chills  and  fever  dependent  upon  septic  processes. 

Prognosis. — The  prognosis  of  malaria  in  children  is  good,  provided 
that  the  child  is  removed   from  the  malarial  district  and  is  treated  with 


482  PEDIATRICS. 

quinine.  Relapses  occur,  even  after  long  intervals  of  apparent  immunity, 
and  the  disease  can  recur  a  number  of  times.  When  a  child  has  been 
once  attacked  by  the  Plasmodium  malariee  it  seems  to  be  peculiarly  vul- 
nerable to  a  second  attack  of  the  organism. 

Prophylaxis. — The  value  of  mosquito-nets  from  a  prophylactic  stand- 
point is  significant,  and  observations  in  malarious  districts  during  the  last 
year  or  two  strongly  support  this  idea.  The  fact  that  a  patient  with  ma- 
larial fever  in  a  malarious  district  is  a  source  of  danger  to  those  about  him 
is  a  very  important  one,  the  deduction  being,  of  course,  that  one  should 
insist  upon  such  an  individual  sleeping  under  a  mosquito-net.  The  im- 
portance also  of  early  and  thorough  treatment  of  all  cases  of  malaria,  par- 
ticularly relapses  in  the  early  malarial  season,  is  evident.  In  some  regions 
destruction  of  the  mosquito  larvae  may  accomplish  a  great  deal,  although 
much  further  research  is  necessary  to  determine  the  places  in  which  these 
particular  varieties  of  mosquito  breed. 

Treatment. — Quinine  is  the  only  drug  which  can  be  relied  upon  to 
eradicate  the  Plasmodium  malarise  from  the  blood,  and  is  therefore  the 
only  medicine  for  this  purpose  which  we  shall  mention. 

The  sulphate  or  hydrochlorate  of  quinine  may  be  given  to  an  infanf 
under  six  months  in  doses  of  0.03  gramme  (J  grain) ;  at  one  year  the  dose 
may  be  0.06  gramme  (1  grain) ;  at  two  years  it  may  be  0.12  gramme  (2 
grains),  and  it  can  be  increased  up  to  0.3  or  0.36  gramme  (5  to  6  grains)  at 
five  and  six  years.  There  is  little  danger  of  giving  too  large  doses  of  quinine 
to  children,  as  they  tolerate  the  drug  very  well.  The  bisulphate  of  qui- 
nine is  much  more  soluble  than  the  sulphate,  and  for  this  reason  is  pre- 
ferred by  many  physicians.  The  hydrochlorate  of  quinine  is  very  much 
more  soluble  in  water  than  either  of  the  sulphates,  requiring  only  thirty- 
five  times  its  own  weight  of  water  as  compared  to  eight  hundred  times  its 
weight  when  the  sulphate  of  quinine  is  used.  The  addition  of  hydrochloric 
or  sulphuric  acid  renders  the  hydrochlorate  of  quinine  soluble  in  less  than 
its  own  weight  of  water,  and  the  sulphate  in  ten  parts  of  its  weight  of 
water.  The  dose  of  the  hydrochlorate  of  quinine  is  the  same  as  that  of 
the  sulphate.  It  is  sometimes  desirable  in  very  severe  cases  to  get  the 
organism  promptly  under  the  influence  of  quinine.  For  this  purpose  the 
very  soluble  double  hydrochlorate  of  quinine  and  urea  may  be  given  sub- 
cutaneously  in  doses  of  0.06  to  0.3  gramme  (1  to  5  grains),  according  to  the 
age  of  the  child.  The  latest  investigations  have  shown  that  the  Plasmo- 
dium is  most  sensitive  to  the  action  of  quinine  when  it  is  corpuscular. 
Hence  the  quinine  should  be  given  shortly  before  the  paroxysm. 

It  has  been  noticed  that  the  administration  of  quinine  tends  to  inter- 
fere Avith  the  regularity  of  the  time  of  the  paroxysm,  and  in  this  way  other 
variations  may  occur.  If  the  paroxysm  comes  earlier  in  the  day  than 
usual,  the  disease  is  apt  to  be  of  a  severe  type  and  to  be  growing  worse, 
while  if  the  interval  is  lengthened  and  the  attack  is  found  to  come 
^t  a,  la,ter  hour  in  the  day  than  usual,  it  is  a  sign  that  the  disease  i§ 


SPECIFIC   INFECTIOUS   DISEASES.  483 

amenable  to  treatment,  is  of  a  benign  character,  and  is  tending  towards 
recovery. 

The  manner  of  administering  quinine  is  rendered  somewhat  difficult 
on  account  of  the  bitter  taste  of  the  drug  and  its  insolubility  in  water. 
In  very  young  infants,  and  in  fact  in  the  first  six  or  eight  months  of  life,  it 
is  well  to  try  the  effect  of  quinine  in  suppositories.  In  older  infants  and 
in  children  it  can  usually  be  successfully  concealed  in  a  small  amount  of 
chocolate  cream.  Quinine  should  never  be  given  in  pill  form,  but  always 
in  capsules  or  in  solution  to  make  sure  that  it  is  absorbed. 

The  time  for  the  administration  of  the  quinine  should  be  regulated 
as  carefully  as  in  the  adult.  The  dose  should  be  given  three  or  four 
times  in  the  twenty-four  hours,  and  one  of  the  doses  should  be  given 
from  four  to  six  hours  before  the  paroxysm,  so  that  the  blood-serum 
shall  be  charged  with  the  quinine  at  the  time  when  the  young  and  more 
sensitive  parasites  have  just  broken  out  from  the  blood-corpuscle.  It  is 
well  to  continue  the  treatment  with  quinine  for  some  weeks  after  the 
paroxysms  have  ceased,  as  the  symptoms  often  return  if  the  quinine  is 
omitted  at  once. 

The  angemia  which  always  accompanies  the  disease  to  a  pronounced 
degree  should  be  treated  with  arsenite  of  potash,  or  with  some  mild  form 
of  iron,  such  as  the  saccharated  carbonate  or  the  tartrate  of  iron  and  pot- 
ash, as  described  under  secondary  antemia,  on  page  911. 

The  following  prescriptions,  varied  to  suit  the  individual,  are  what  we 
are  in  the  habit  of  using  in  cases  of  malaria  : 

Pkescriptiox  35. 

For  an  Infant  under  Six  Months. 
Metric.  Afotheeary. 

Gramma. 

R    Quininse  hydrochloralis 0 

Olei  theotromiB 11 


36         R    Quininffi  hydrochloratis gr.  vi  ; 

25  Olei  theobromje ziii. 


M.  M. 

Ft.  suppos.  no.  12.  Ft.  suppos.  no.  12. 

S. — One  suppository  to  be  used  every  6  houre. 

Prescription  36. 

For  Older   Children. 
Metric.  Apothecary. 

Gramma. 


R    Quininas  hydrocliloratis 6 

Acidi  hydrochlorici  dil q.s. 

Aquae  destillatse 60 

M.  M. 

Sig. — Teaspoonful  once  in  6  hours 


00         R    Quininse  hydrochloratis ^iss ; 

Acidi  hydrochlorici  dil q.s. 

00  Aquae  destillatse ^  ii 


The  following  case  of  an  infant,  a  few  days  old,  was  probably  one  of 
malaria,  but  no  examination  of  the  blood  was  made : 

The  infant's  mother  had  malaria  during  her  pregnancy,  and  some  of  the  manifes- 
tations of  the  disease  appeared  ten  days  before  the  birth  of  the  infant.     The  infant 


484 


PEDIATHR'S. 


from  the  earliest  days  of  its  life  showed  symptoms  of  severe  digestive  disturbance, 
characterized  by  vomiting  and  diarrhcea,  and  far  beyond  what  could  be  accounted  for 
by  the  lack  of  equilibrium  of  the  function  of  the  mother's  mammary  gland.  A  care- 
ful physical  examination  failed  to  detect  anything  abnormal  ni  its  thorax  or  abdomen. 
Observations  of  the  temperature  in  this  case,  taken  both  in  the  axilla  and  in  the  rec- 
tum, showed  that  it  was  of  an  irregular  type,  varying  from  37.2°  to  38.3°  C.  (99° 
to  101°  F.)  rectal,  and  that  at  times  in  the  latter  part  of  the  day  it  rose  to  39.4° 
to  40°  C.  (103°  to  104°  F.)  axillary.  Every  day  at  about  1  a.m.  there  was  a  parox- 
ysm, represented  by  cyanosis,  coldness  of  the  entire  skin,  both  of  the  body  and  of  the 
extremities,  collapse,  and  somnolence.  These  attacks,  beginning  at  the  seventh  day  of 
life,  lasted  until  the  twelfth  day,  when  quinine  in  0.03  gramme  (^  grain)  doses,  given 
in  suppositories  and  administered  every  two  hours  for  seven  doses,  at  once  and  com- 
pletely checked  the  paroxysms.  From  this  time  the  attacks  entirely  disappeared,  the 
food  was  well  digested,  and  the  infant  seemed  perfectly  well. 

The  following  cases  occurred  in  our  service  at  the  Children's  Hospital  : 

A  boy,  nine  years  old,  was  admitted  on  the  13th  day  of  February.  He  lived 
in  a  malarial  district  until  one  year  ago.  He  had  had  a  slight  cough,  anorexia,  malaise, 
night-sweats,  and  rapid  loss  of  flesh  for  several  weeks.  The  movements  of  the  bowels 
were  rather  irregular.  According  to  his  mother's  report,  he  had  never  before  had 
any  symptoms  of  malaria.  The  child  was  pale  and  emaciated.  On  physical  exami- 
nation there  was  resonance  over  both  lungs,  and  on  auscultation  a  few  moist  rales  and 
an  occasional  sibilant  rale  were  heard.     The  area  of  cardiac  dulness  and  the  sounds 


Fto.  U.S. 


Boy,  9  years  old.     Enlarged  spit 


I'lasmoJium  nialari^e  found  iti  the  blood. 


of  the  heart  wei-e  normal.  The  liver  was  not  enlarged,  but  the  spleen  was  very 
much  increased  in  size,  the  limits  of  its  enlargement  are  marked  in  black  in  Fig. 
113.  The  upper  border  rose  as  high  as  the  sixth  rib  in  the  axillary  line,'  and  extended 
down  into  the  left  inguinal  region.     The  urine  was  normal. 

Th'e  case  represented  the  tertian  f(jnii  of  malaria.      The  child  \v.u\  urvpr  had  a  diill 


SPECIFIC    INFECTIOUS    DISEASES. 


485 


until  3  P.M.  two  days  after  entering  the  hospital.  The  chill  lasted  about  one  hour,  and 
was  followed  by  sweating.  A  paroxysm  of  some  kind,  represented  either  by  a  chill 
or  by  a  decided  rise  in  temperature  with  chilly  sensations,  occurred  on  the  17th,  19th, 
21st,  23d,  25th,  27th,  and  29th  of  February,  March  2,  and  March  4,  and  on  March  6 
there  was  a  decided  rigor  at  4  p.m.  On  March  8  the  paroxysm  occurred  in  the  morn- 
ing at  half-past  twelve.  On  the  morning  of  March  10  the  paroxysm  occurred  at  about 
half-past  eleven,  and  was  followed  by  marked  sweating.  Between  the  paroxysms  the 
boy  appeared  to  be  very  well.  He  had  a  fair  appetite,  and  gradually  gained  in  weight 
and  strength. 

On  March  10,  immediately  after  the  paroxysm,  the  blood  shov/ed  the  Plasmodium 
malaripe.  The  appearance  of  the  blood  in  this  case  is  shown  on  Plate  XII.,  facing  page 
874.      The  count  gave  the  following  results  : 

Erythrocytes    2,935,000 

Haemoglobin 36  per  cent. 

Leucocytes 25, 500 

A  large  number  of  the  erythrocytes  contained  the  plasmodium  malarias.  The 
leueocytosis  nointed  towards  some  complication,  but  none  was  at  any  time  discovered. 


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Pure  tertian  form  of  malaria.     (Craeans  chill. 1 


The  chills  continued  on  March  12,  14,  and  16.     On  March  17,  0.36  gramme  (6  grains) 
of  quinine  was   given  six   hours  before   the  paroxysm  was  expected  to  return.      On 


486 


PEDIATRICS. 


March  18  there  was  no  paroxysm.  The  quinine  was  given  regularly  three  or  four 
times  a  day  for  several  days,  and  tlie  paroxysms  did  not  return. 

Chart  16  represents  the  temperature  and  pulse  of  this  case.  The  days  representing 
the  disease  were  necessarily  only  approximate  for  the  first  twenty-two  days,  and  the 
child  was  supposed  to  have  entered  the  hospital  on  the  twenty-third  day  of  the  disease. 
The  first  chill  occurred  on  the  twenty-fifth  day,  as  is  shown  in  the  chart. 

Subsequently  the  quinine  was  omitted,  the  chills  did  not  return,  the  spleen  re- 
covered its  normal  size,  the  antemia  disappeared,  and  the  child  grew  fat,  and  left  the 
hospital  in  good  condition. 

The  second  case  was  that  of  a  girl,  nine  years  old,  who  entered  the  hospital  also 
on  the  13th  of  the  month.  She  represented,  in  contradistinction  to  the  tertian  form 
of  malaria  seen  in  the  boy,  a  case  of  the  double  tertian  (quotidian)  form.  She  had 
been  living  in  a  malarial  district,  but  had  never  had  any  previous  symptoms  of  malaria, 

Fig.  114. 


Girl,  9  yeajs  old.    Enlarged  spleen.    Plasmodium  malarise  found  in  the  blood. 


although  a  sister  living  in  the  same  house  had  been  affected  by  the  disease.  ■  Four 
weeks  before  entering  the  hospital  she  had  an  attack  of  vomiting,  nausea,  and  head- 
ache, without  any  apparent  cause.  These  symptoms  recurred  at  intervals  for  two  weeks, 
when  she  began  to  have  chills  occurring  every  day  at  about  6  p.m.  These  chills  con- 
tinued, with  the  exception  of  four  days,  until  her  entrance  to  the  hospital. 

She  was  fairly  developed  and  was  very  anaemic.     On  physical  examination  moist 
rales  were  heard  over  the  bases  of  the  lungs  behind.     The  heart  showed  no  increase  in 


SPECIFIC    INFECTIOUS    DISEASES. 


487 


the  area  of  dulness,  but  there  was  a  soft  systolic  murmur  over  the  whole  prsecordia. 
This  murmur  was  most  intense  over  the  pulmonic  area.  The  pulmonic  second  sound 
was  not  accentuated.  The  murmur  was  heard  in  the  jugular  veins.  An  examination 
of  the  abdomen  showed  it  to  be  soft  and  tympanitic.  The  liver  was  enlarged,  so  that  it 
extended  2.5  cm.  (1  inch)  below  the  border  of  the  ribs.  The  edge  of  the  spleen  was 
plainly  felt,  and  the  percussion  dulness  extended  downward  to  the  level  of  the  umbili- 
cus and  upward  as  far  as  the  sixth  rib,  and  is  designated  by  a  black  line,  as  seen  in 
Fig.  114.  The  urine  was  high-colored  and  had  a  specific  gravity  of  1025,  but  was 
otherwise  normal. 

CHAKT  17. 


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Double  tertian  form  of  malaria  (quotidian),     (e,  chills.) 

On  the  day  of  entering  the  hospital  (the  13th)  the  child's  temperature  was  raised, 
but  there  was  no  chill.  On  the  following  day,  the  14th,  there  was  a  chill  at  4  p.m. 
On  the  15th  there  was  a  marked  chill,  with  a  considerable  rise  of  temperature. 

Immediately  after  the  paroxysm  an  examination  of  the  blood  was  made  with  the 
following  result  : 

Erythrocytes 3,396,250 

Haemoglobin   30  per  cent. 

Leucocytes 5,000 

Plasmodium  malariee  present. 

It  was  noted  that  the  splenic  enlargement  was  greatest  during  the  chill. 
On  the  16th  there  was  a  chill,  and  the  temperature  rose  to  40.6°  C.  (105.2°  F.), 
the  maximum  attained  during  the  course  of  the  disease. 


4X8  PEDIATUICS. 

Oil  the  17lh  and  18th  tlie  chills  recurred. 

On  the  18lh  0.36  gramme  (6  grains)  of  sulphate  of  quinine  was  given  at  12.30  p.m. 

On  the  19th  there  was  no  rise  in  the  temperature,  and  no  quinine  was  given. 

On  the  20th  and  21st  there  were  no  chills,  but  a  slishl  rise  of  temperature,  and 
0  12  gramme  (2  grains)  of  quinine  was  given  four  times  daily. 

On  the  22d  slie  had  a  chill,  and  the  temperature  was  40.50  C.  (105°  F,). 

For  the  next  sixteen  days  0.6  gramme  (10  grains)  ot  q>iinine  wns  given  in  the 
course  of  each  twenty-four  hours,  the  spleen  gradually  growing  smaller.  As  the  tem- 
perature was  still  irregular,  tiie  quinine  was  then  increased  to  0.72  gramme  (12  grains). 
The  temperature  remained  normal  for  three  days,  and  then  was  again  slightly  raised 
and  irregular.      Two  weeks  later  the  quinine  was  omitted. 

The  following  are  the  records  of  two  infanls  who  apparently  were 
suffering  from  the  effects  of  the  plasmodium  malariae,  although  no  exam- 
ination of  their  blood  was  made  : 

The  first  one  was  one  year  and  ten  months  old.  The  infant  had  lived  in  a  mala- 
rial district  until  within  a  few  weeks  of  the  time  when  we  saw  him. 

The  history  which  was  given  by  his  mother  was  that  for  several  weeks  he  had  liad 
attacks  represented  by  a  chill  or  chilly  sensations,  occurring  every  day  about  noon. 
These  attacks  had  recurred  for  about  a  week  or  ten  days  before  we  saw  him.  In  con- 
nection with  the  chill  and  the  fever  the  infant  usually  became  unconscious,  and  its  feet 
and  hands  w-ere  cold  and  clammy. 

0.06  gramme  (1  grain)  of  quinine  was  given  to  the  infant  on  the  29th  of  April, 
and  on  the  following  day  none  of  the  usual  manifestations  occurred  at  noon,  but  at 
about  4.30  p.m.  he  had  a  chill  and  a  slight  rise  of  temperature,  but  was  not  unconscious. 
0.03  gramme  (J  grain)  of  quinine  was  then  given,  and  on  the  following  day,  April 
30,  0.06  gramme  (1  grain)  of  quinine  at  10.30  .a.m.  On  this  day  there  was  a  decided 
chill,  and  the  rectal  temperature  rose  to  40.5°  C.  (105°  F.).  During  the  attack  the 
child  breathed  rapidly  ;  its  feet,  hands,  and  nose  became  cold,  and  it  w'as  practically 
unconscious  for  some  minutes  until  its  circulation  was  restored  by  injections  of  warm 
water  and  brandy.  0.03  gramme  {h  grain)  of  quinine  was  then  given  three  times 
during  the  twenty-four  hours.  On  the  following  day  none  of  these  abnormal  symptoms 
occurred.  On  the  next  day  0.03  gramme  {h  grain)  of  quinine  was  given  in  the  morn- 
ing and  again  at  night,  and  this  dose  was  continued  for  a  few  days.  From  this  time' 
the  symptoms  of  malaria  entirely  disappeared,  the  infant  grew  less  and  less  emaciated, 
became  stronger,  had  a  good  appetite,  and  continued  to  thrive.  No  enlargement  of  the 
spleen  was  detected  in  this  case 

The  next  infant  was  nineteen  months  old,  and  was  brought  from  a  decidedly  mala- 
rial district. 

It  had  previously  been  well  until  three  weeks  before  it  was  brought  to  be  treated  for 
the  following  symptoms.  At  the  time  when  its  bath  was  given  to  it,  which  was  be- 
tween 11  and  12  in  the  morning,  it  had  symptoms  characterized  by  drowsiness  and 
cyanosis,  and  it  would  fall  asleep,  and  after  about  half  an  hour  would  wake  up  bright 
and  well.  These  attacks,  although  short  in  duration,  were  very  alarming  and  apparently 
serious,  as,  although  the  infant  did  not  have  any  pain  or  convulsions,  it  could  not  be 
roused  while  in  the  attacks,  and  became  so  blue  and  cold  that  it  was  feared  that  it 
might  die  in  one  of  them.  At  the  time  of  the  attacks  the  rectal  temperature  varied 
somewhat,  but  was  usually  about  38.3°  C.  (101°  F.). 

The  treatment  of  this  case  was  with  sulphate  of  quinine,  sometimes  given  by  the 
mouth  and  sometimes  by  means  of  rectal  suppositories.  After  the  administration  of 
the  quinine  for  four  or  five  days  the  attacks  entirely  ceased  and  did  not  return.  The 
infant  from  that  time  continued  to  thrive. 


SPECIFIC    IXFECTIOUS    DISEASES.  489 

TETANUS  NEONATORUM. 

Tetanus  neonatorum  is  an  acute  infectious  disease,  usually  occurring 
in  infants  from  the  third  t<:)  the  twelftli  day  of  life,  and  is  almost  ahvays 
fatal  in  two  or  three  weeks. 

Etiology. — The  cause  of  the  disease  is  the  same  as  that  of  tetanus  in 
the  adult, — that  is,  the  baeiUus  of  tetanus, — and  the  organism  is  supposed 
usually  to  gain  its  entrance  at  the  umbilicus.  This  disease  is  epidemic  in 
tropical  climates,  but  as  we  see  it  is  usually  of  a  sporadic  nature. 

Symptojis. — After  considerable  restlessness  and  muscular  twitchmg, 
lasting  for  some  hours,  the  infant  assumes  a  very  characteristic  appear- 
ance. There  is  extreme  rigidity  of  the  legs  and  body.  This  rigidity 
sometimes  takes  the  form  of  opisthotonos  and  trismus  (rigidity  of  the  in- 
ferior maxilla).  The  eyes  are  almost  closed,  but  the  infant  is  sleepless. 
The  trunk  and  limbs  are  so  stiff  that  the  infant  remains  in  whatever 
position  it  is  placed.  It  is  unable  to  nurse,  and  has  a  higli  temperature, 
occasionally  reaching  40°  C.  (104°  F.),  and  a  pulse  of  150  or  160.  At 
times  it  will  have  slight  convulsive  attacks. 

Prognosis. — It  is  extremely  fatal.  When  recovery  takes  place  the 
improvement  is  very  gradual,  the  temperature  and  pulse  decreasing  and 
the  rigidity  of  the  muscles  passing  away  very  slowly,  with  at  times  a  re- 
currence of  the  symptoms. 

Treatment. — The  treatment  of  this  disease  has  thus  far  been  very 
unsatisfactory^  The  possibility  of  successfully  treating  these  cases  with 
the  antitoxin  of  tetanus  must  be  considered  ;  but  the  results  so  far  obtained 
have  not  been  brilliant,  and  it  is  doubtful  if  the  cases  so  treated  show  a 
lower  mortality  than  those  in  whom  the  treatment  has  been  only  symp- 
tomatic. 

The  form  of  treatment  which  appears  most  rational  is  to  place  the 
child  during  the  continuation  of  the  tonic  spasm  in  a  Avarm  bath  and 
to  give  it  0.06  gramme  (1  grain)  of  hydrate  of  chloral  every  hour  until  the 
effects  of  the  drug  are  shown  by  the  lessening  of  the  muscular  rigidity 
and  by  a  disposition  to  sleep.  In  addition  to  this  treatment,  small  c]uan- 
tities  of  milk,  15  c.c.  (about  }  ounce),  should  be  given  to  the  infant  by 
means  of  a  dropper  every  hour,  and  to  each  feeding  three  minims  of 
brandy  or  some  other  stimulant  should  be  added.  Under  this  treatment  a 
certain  number  of  cases  have  been  known  to  live. 

The  following  case  may  be  considered  as  one  of  the  milder  forms  of 
tetanus  neonatorum : 

An  infant,  said  to  have  been  healthy  at  birth  and  to  have  nursed  without  difficulty 
during  the  first  week  of  its  life,  refused  to  nurse,  apparently  from  inability  to  open  its 
jaws.  It  sometimes  cried,  but  feebly.  There  were  no  convulsions,  no  vomiting,  and 
no  rigidity  in  any  other  part  of  the  body.  The  temperature  was  not  taken.  On  physi- 
cal examination  it  was  found  that,  although  the  infant  could  swallow,  the  jaw  could 
not  be  opened  wider  than  1.2  cm.  (^  inch).      On  forcing  the  finger  between  the  jaws. 


490  PEDIATRICS. 

nothing  abnormal  was  discovered  in  the  mouth  or  pharynx.  The  respiration  was 
regular,  but  rather  shallow,  and  there  Avas  no  evidence  of  injury.  Nothing  else  ab- 
noi'mal  was  discovered. 

It  was  given  0.06  gramme  (1  grain)  of  hydrate  of  chloral  three  or  four  times  in 
the  twenty-four  hours,  and  two  days  later  showed  marked  improvement,  with  the  excep- 
tion of  still  being  unable  to  open  the  jaws  widely,  nothing  else  abnormal  was  discovered. 
The  rectal  temperature  subsequently  became  normal,  and  it  finally  recovered. 

ERYSIPELAS. 

En^sipelas  is  an  infectious  disease,  caused  by  the  streptococcus  pyo- 
genes. The  term  is  apphed  to  an  inflammation  of  the  skin,  subcutaneous 
tissue,  and  mucous  membranes  which  has  the  following  characteristics. 
It  especially  involves  the  lymph,-spaces  and  lymph-vessels.  It  has  a 
tendency  to  spread,  and  is  attended  by  unusual  swelling  of  the  sub- 
cutaneous tissue  and  an  intense  red  color  of  the  skm  or  the  mucous 
membrane.  In  addition  to  these  local  appearances  it  is  accompanied  by 
constitutional  symptoms,  which  are  mostly  the  result  of  a  heightened 
temperature. 

The  disease  runs  an  acute  course,  is  contagious,  enters  the  individual 
through  some  abrasion  of  the  skin  or  mucous  membrane,  and  is  self- 
limited. 

Pathological  Anatomy. — The  tissues  may  be  swollen  by  an  accumula- 
tion of  serous  fluid,  which  may  be  nearly  transparent,  or  turbid  from 
admixture  with  pus-cells.  The  pus-cells  may  infiltrate  the  tissues  either 
sparsely  or  in  dense  masses.  Sometimes  vesicles  are  found  on  the  surface, 
or  there  may  be  crusts.  At  times  more  or  less  of  the  affected  region  is  filled 
with  abscesses  or  becomes  gangrenous.  In  other  cases,  aside  from  the  local 
lesions  petechiae  are  found  in  the  serous  membranes,  and  swelling  of  the 
spleen  and  parenchymatous  degeneration  of  the  kidneys  and  liver.  When 
the  mucous  membranes  are  affected  they  show  the  same  appearances  as 
the  lesions  of  the  skin,  except  so  far  as  these  are  modified  by  the  different 
structm-e  of  the  tissue.  The  disease  may  attack  the  larynx  and  upper 
air-passages  and  result  in  oedema.  Pneumonia  may  occur  as  a  compli- 
cation. 

Although  the  different  organs,  such  as  the  spleen,  kidney,  heart,  and 
liver,  at  times  show  pathological  changes,  nothing  characteristic  of  erysip- 
elas has  been  found  in  these  organs,  but  only  such  changes  as  may  occur 
from  a  continued  high  temperature  or  as  the  result  of  sepsis. 

Symptoms. — Erysipelas  may  be  divided  into  two  forms, — migrans,  ex- 
tendmg  from  surface  to  surface,  and  ambulans,  occurring  in  different  parts 
of  the  skin.  It  may  also  be  acute  or  chronic.  In  erysipelas  migrans, 
which  is  the  most  common  form,  the  whole  surface  of  the  body  may  be 
attacked.  It  is  very  prone  to  return,  passing  over  the  same  surfaces  of 
the  skin  again.  The  face  and  head  are  not  so  commonly  attacked  in 
infants  as  in  adults,  and  the  disease  seldom  spreads  from  another  part  of 
the  body  to  the  head.     When  it  does  attack  the  head,  it  is  apt  to  be  fatal 


SPECIFIC   INFECTIOUS   DISEASES.  491 

from  a  secondary  purulent  meningitis.  It  at  times  causes  great  swelling  and 
tension,  and  may  go  on  to  gangrene  in  certain  localities,  such  as  the  scrotum. 

The  stage  of  the  incubation  of  erysipelas  lasts,  according  to  Osier, 
from  three  to  seven  days. 

After  the  first  year  erysipelas  so  closely  resembles  the  disease  as  it 
occurs  in  adults  that  we  heed  not  consider  it  in  this  later  period  of  life. 
It  is  a  somewhat  frequent  disease  in  infants  up  to  six  months  of  age. 
It  then  becomes  less  frequent  up  to  the  first  year,  and  after  that  and  in 
childhood  is  rather  rare.  We  shall,  therefore,  speak  of  erysipelas  as  it 
affects  infants  only. 

The  erysipelas  of  infancy  may  be  divided  into  erysipelas  of  the  new-born 
and  erysipelas  of  sucklings. 

Erysipelas  of  the  New-Born. — When  erysipelas  occurs  before  the 
end  of  the  third  week  the  infant  seldom  lives,  and  indeed  it  is  a  most 
dangerous  disease  up  to  the  end  of  the  third  or  fourth  month.  Erysipelas 
of  the  new-born  is  apt  to  occur  during  an  epidemic  of  puerperal  fever.  If 
the  mother  has  any  septic  symptoms,  the  infant  should  be  immediately 
taken  away  from  her.  We  have  seen  a  case  where  the  mother  had 
puerperal  peritonitis  following  her  delivery,  and  the  infant,  who  was 
allowed  to  nurse  her,  was  attacked  by  erysipelas. 

In  many  cases  occurring  in  the  early  days  of  life  the  disease  starts  on 
the  genitals,  and  may  be  complicated  by  other  diseases,  such  as  empyema 
and  especially  pneumonia.  During  the  course  of  the  disease  the  fonta- 
nelle  sinks,  the  spleen  is  enlarged,  convulsions  may  occur,  and  peritonitis 
accompanied  by  vomiting  may  arise  as  a  complication.  The  disease  is 
liable  to  invade  the  tissues  at  any  point  of  abrasion,  whether  from  the 
forceps  or  from  vaccination,  or  at  the  point  of  separation  of  the  um- 
bilical cord.  The  latter  is  the  most  common  locality  for  the  infection  to 
take  place.  From  this  point  the  infection  may  extend  and  produce  a 
gangrenous  condition  of  the  stomach  or  abdomen. 

Although  the  temperature  in  the  early  hours  or  even  days  of  the 
disease  may  not  be  raised,  yet,  as  a  rule,  fever  soon  appears,  the  temper- 
ature varying  from  39°  to  41°  C.  (102.2°  to  105.8°  F.).  Reddening 
and  swelling,  not  of  a  high  grade  at  first,  appear  on  the  part  affected. 
The  infants  show  symptoms  of  a  general  sepsis.  Vomiting  frequently 
occurs,  followed  by  collapse  and,  almost  without  exception,  by  death. 

Treatment. — The  treatment  of  this  severe  form  of  erysipelas  is  by 
stimulants  and  a  substitute  food  adapted  to  the  infant's  digestion. 

Erysipelas  of  Suckling-s. — When  the  disease  occurs  in  the  early 
months  of  life,  its  beginning  is  usually  accompanied  by  cold  extremities 
and  collapse.  The  temperature  is  raised,  and  the  higher  its  degree  the 
graver  the  prognosis.  The  temperature  curve,  as  a  rule,  is  intermittent 
with  considerable  morning  and  evening  variations,  except  in  the  more 
severe  forms,  in  which  there  is  continued  high  fever  ;  in  the  latter  cases 
icterus  is  apt  to  develop. 


41)2  PEDIATRICS. 

TliP  efflorescence,  although  very  siiiiilur  tn  that  which  is  seen  in  tlie 
adult,  differs  somewhat  on  account  of  the  innro  delicate  structure  of  tlic 
infant's  skin.  It  begins  as  a  faint  erythema,  which  spreads  rapidly  and 
as  tfuickly  disappears,  sometimes  within  twenty-four  hours,  and  twenty- 
four  hours  later  desquamation  may  occur.  The  light  color  of  the  efflo- 
rescence soon  becomes  darker  and  more  uitense.  and  is  accompanied  by 
swelling,  heat,  and  tension  of  the  subcutaneous  tissue.  After  the  efflo- 
rescence has  continued  for  a  certain  number  of  days,  depending  upon 
the  amount  of  the  surface  of  the  skin  involved,  the  extension  rif  tlie 
disease  ceases  and  the  temperature  falls.  The  redness  gradually  disap- 
pears, and  the  skin  becomes  covered  with  yellowish-brown  crusts. 
Finally,  descjuamation  takes  place,  and  the  skin  recovers  its  normal 
appearance,  the  disease  extending  over  a  variable  period  according  to 
tlie  greater  or  less  extent  of  the  surfaces  invaded. 

Although  the  disease  when  involving  large  surfaces  is  dangerous,  yet 
cases  in  the  later  months  of  infancy  recover  even  when  the  attack  has 
been  a  severe  one.  An  instance  of  this  kind  came  to  our  notice  in  which 
an  infant  ten  months  old  was  attacked  with  erysipelas,  the  point  of  infec- 
tion being  the  right  labium. 

Ill  this  case  the  whole  vulva  shortl)'  hecame  very  lender  and  the  disease  extended 
to  the  pubes  and  abdomen.  It  invaded  every  part  of  the  body  and  extremities  and 
the  head  and  neck.  The  eyeUds  and  lips  were  the  last  points  of  attack.  Even  the 
palms  of  the  hands  and  soles  of  the  feet  were  affected.  From  the  time  that  it  ap- 
peared at  one  part  of  the  body  until  the  skin  of  that  part  assumed  its  normal  color 
asrain  was  four  days.  When  the  erysipelatous  inflammation  extended  to  the  feet  there 
was  marked  oedema.  The  duration  of  Ihe  attack  from  its  first  appearance  at  the  vulva 
lo  lis  disappearance  at  the  eyes  and  mouth  was  about  fifteen  days.  The  infant  was 
treated  with  small  doses  of  iron  and  quinine,  and  recovered  entirely. 

Tre.\tment. — Xo  treatment  of  which  we  know  is  of  any  avail  in  cutting 
short  the  disease,  in  early  life.     According  to  Dr.  J.  C.  "White,  the  exten- 
sion of  the    efflorescence  in  adults    can    be    controlled  and   the   attack 
-  frecjuently  aborted  by  the  continuous  application  of  the  following  wash  : 

Prescription'  37. 
Mt'lrk:  - 1 polhecavi/. 

Gramma. 

R    Acidi  carbolici  (xtals) ,:^  i  ; 

Alcohol, 


K;     Acidi  carbolici  (xtals) 
Alcohol, 


Aquae ;    .      .    .  .   aa  240,  Aqupe 


In  using  this  wash  one  must  bear  in  mind  the  great  susceptibility  of  in- 
fants to  carbolic  acid  poisoning,  as  shown  by  the  passage  of  dark  colored 
urine. 

One  may  also  use  a  wash  composed  of  equal  parts  of  alcohol  and  lime- 
water,  with  zinc  oxide  powder  added  in  the  proportion  of  1  ounce  to  8  of 
the  liquid. 

Where  large  surfaces  are  affected,  the  application  of  cold  compresses 


SPECIFIC    LNTECTIOUS    DISEASES. 


493 


tends  to  depress  the  vitality  of  tlie  infant,  which  it  is  so  important  to  sus- 
tain. During  the  height  of  the  disease  the  infant's  strength  should  be 
supported  by  stimulants  and  by  the  frequent  administration  uf  a  food 
adjusted  to  its  digestion. 

Plate  X.,  facing  page  610,  represents  the  typical  efflorescence  of  the 
erysipelas  of  sucklings  as  it  occurred  i:i  a  female  infant  six  months  old. 

It  had  always  been  healthy,  aud  was  nursed  until  within  three  weeks  of  the  time 
of  entrance,  when  it  A%'as  weaned  from  the  mother  and  nursed  by  another  woman.  It 
was  of  normal  weight  and  general  development. 

The  first  symptoms  which  were  noticed  were  vomiting  and  a  temperature  of  39.5° 
C.  (103. o°F.)  in  the  axilla.  It  seemed  weak  and  languid,  looked  badly,  and  refused 
to  take  the  breast.  An  examination  of  the  breast-milk  showed  a  peculiar  green  color, 
which  not  only  appeared  in  the  milk  when  drawn  from  the  breast,  but  also,  when  the 
analyst--  was  made,  appeared  in  the  curd  resulting  from  the  precipitation  of  the  pro- 
teids.  The  analysis  of  the  milk  was  as  follows.  The  nature  of  the  micro-organism 
which  produced  the  green  color  was  not  determined. 

Fat 4.56 

Sugar 6. 36 

Proteid; -3.46 

Mineral  matter 0.1-3 

Later  in  the  day  a  pink  efflorescence  appeared  just  above  the  pubes,  and  there 
was  found  to  be  considerable  irritation  in  the  neighborhood  of  the  vagina.  The  red- 
ness extended  from  the  vagina  to  the  suprapubic  efflorescence.     The  efflorescence  was 


CHAir 

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Daj/s  of 2?Lsease 

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106° 
105° 
104° 
103° 
102° 
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MOaMT. 
TEVTR 

98° 
97° 
96° 

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5 

6 

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ISJK 

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16 

17 

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19 

20 

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36  5° 

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— 

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i          i 

Er\-sipela5  of  lears.    Female,  6  months  old. 

of  an  erythematous  type.  On  the  following  day  it  spread  to  the  left  thigh,  and 
then  to  the  left  lower  leg.  The  temperature  continued  to  be  raised,  and  the  infant 
refused  to  nurse.  Small  quantities  of  a  substitute  food  A\-ith  the  following  percentages, 
which  had  to  be  varied  from  dav  to  dav,  were  iriven  to  it : 


494  PEDIATRICS. 

Prescription  38. 

Fat 2.50 

Sugar 6.00 

Proteids 1 .50 

There  were  no  convulsions  or  other  symptoms,  hut  tlie  infant  lost  somewhat  in 
strength  and  weight  and  its  face  looked  pinched. 

The  efflorescence  on  the  left  leg  began  to  fade  on  the  ninth  day  of  the  disease, 
and  on  the  tenth  day  the  temperature  became  almost  normal.  On  the  following  day, 
however,  it  again  rose,  and  a  fresh  efflorescence  began  to  appear  on  the  right  thigh 
continuous  with  the  efflorescence  of  the  suprapubic  region.  This  efflorescence  ex- 
tended down  the  right  leg  to  the  ankle. 

On  the  twelfth  day  the  skin  of  the  left  leg  was  in  some  places  almost  normal,  in 
others  was  covered  by  thin  brownish-yellow  crusts.  The  suprapubic  region  and  the 
right  leg  as  far  as  the  ankle  were  covered  with  a  bright  red  efflorescence  sharply 
bounded  by  normal  skin  below,  just  above  the  ankle,  as  though  it  were  a  stocking. 
The  whole  leg  was  swollen,  was  hotter  to  the  touch  than  the  sound  skin,  and  presented 
a  somewhat  raised,  glistening  appearance. 

No  external  applications  and  no  drugs  were  employed  in  this  case.  The  milk 
was  carefully  modified,  and  small  doses  of  brandy  were  given. 

A  few  days  later  the  temperature  became  normal,  the  efflorescence  began  to  fade, 
desquamation  subsequently  took  place,  and  the  skin  finally  recovered  its  iiormal  ap- 
pearance. The  infant  gradually  regained  its  strength,  became  perfectly  well,  and  had 
no  return  of  the  disease. 

Chart  18  shows  the  temperature  during  the  course  of  the  erysipelas  in  this  case. 

This  form  of  erysipelas  may  become  chronic,  and  this  is  more  apt  to 
occur  in  children  than  in  infants.  It  is  also  most  common  in  children 
who  are  in  a  debilitated  condition,  and  may  occur  at  intervals  of  three  or 
four  years.  It  is  in  older  children  frequently  connected  with  chronic  in- 
flammations of  the  Schneiderian  membrane,  and  in  these  cases  is  peculiarly 
intractable  to  treatment. 

AMCEBA   COLL 

Etiology. — x\nother  form  of  infectious  diarrhoea  which  has  been  called 
tropical  or  endemic  dysentery  is  a  specific  infectious  disease,  caused  by  a 
well-recognized  organism  called  the  amoeba  coli.  The  amoeba  coli  is  an 
animal  micro-parasite  belonging  to  the  group  of  protozoa.  The  disease  is 
of  rare  occurrence  in  children,  and  is  very  infrequent  in  northern  climates. 
It  is  seen  for  the  most  part  in  the  tropics.  A  common  source  of  infection 
is  by  means  of  drinking-water. 

Pathological  Anatomy. — The  disease  has  its  own  definite  anatomical 
lesions,  which  consist  of  round,  oval,  or  irregular  ulcers,  the  edges  of  which 
are  infiltrated  and  undermined,  so  that  individual  ulcers  may  be  connected 
by  submucous  sinuses.  Amoebse  are  found  in  the  lesions  and  in  the  intes- 
tinal discharges.  The  large  intestine  is  more  commonly  the  seat  of  the 
disease,  especially  the  caecum,  hepatic  and  sigmoid  flexures,  and  the  rectum. 

The  disease  may  advance  by  progressive  infiltration  of  the  connective 
tissue  of  the  intestines,  giving  rise  to  large  sloughs.     In  the  same  manner 


SPECIFIC   INFECTIOUS   DISEASES.  495 

the  liver  may  become  infected,  producing  lesions  in  the  nature  either  of 
local  necroses  of  the  parenchyma  or  of  abscesses,  which  may  be  single  or 
multiple.  Cultures  taken  from  the  abscesses  are  generally  sterile,  but  the 
amoebee  may  be  in  the  walls  of  the  abscesses.  Similar  abscesses  found 
within  the  lungs  are  a  result  of  direct  extension  from  the  liver  through 
the  diaphragm. 

Symptoms. — The  disease  is  usually  acute  in  its  onset,  but  sometimes  it 
may  be  gradual.  The  duration  may  be  two  or  three  months.  The  diar- 
rhoea at  first  may  be  transient  and  triflmg  in  character,  but  in  the  severe 
gangrenous  forms  is  abrupt  and  intense.  The  course  of  the  disease  is 
irregular.  The  diarrhoea  is  characterized  by  exacerbations  and  remissions, 
and  progressive  loss  of  flesh  and  strength.  The  fever  is  moderate,  and  in 
some  cases  is  absent.  Nausea,  vomiting,  abdominal  pain,  and  tenderness 
are  usually  only  present  in  the  severer  forms.  The  stools  present  a 
variety  of  appearances  ;  they  are  generally  watery  and  mixed  with  mucus, 
and  sometimes  with  blood,  but  in  the  intermissions  and  convalescence  are 
formed.  The  amoebge,  with  their  characteristic  movements,  may  be  found 
when  the  stools  are  fluid,  but  rarely  if  they  are  formed. 

Diagnosis. — There  are  no  especial  symptoms  by  which  to  distinguish 
this  form  of  infectious  diarrhcea  from  other  forms,  which  are  described  on 
page  815,  and  the  only  positive  proof  of  the  existence  of  the  disease  is  the 
presence  of  the  amcebce  in  the  discharges. 

Prognosis, — The  prognosis  is  very  unfavorable.  Recovery  is  slow. 
The  anemia  and  weakness  delay  convalescence,  and  relapses  are  com- 
mon.    An  involvement  of  the  liver  generally  leads  to  a  fatal  issue. 

Treatment. — The  treatment  which  has  been  followed  by  the  most 
favorable  results  is,  in  addition  to  frequent  and  thorough  irrigation  of  the 
intestine,  injections  of  solutions  of  sulphate  of  quinine  (1  to  5000).  This 
treatment,  however,  affects  only  the  amoebte  which  are  in  the  intestine, 
and  not  those  which  are  embedded  in  the  tissues.  The  antemia  should 
be  treated  as  described  on  page  911.  The  diet  should  be  carefully  regu- 
lated and  adapted  to  the  age  of  the  individual.  Milk,  beef-juice,  egg 
albumin,  and  broths  should  constitute  the  principal  food,  and  in  the  con- 
valescence it  is  necessary  to  exercise  especial  care  in  the  management  of 
the  digestion. 

CHOLERA  ASIATICA. 

Cholera  Asiatica  is  a  highly  infectious  disease,  caused  by  the  comma 
bacillus  of  Koch,  which  manifests  its  most  violent  symptoms  in  the  gastro- 
enteric tract.  Its  symptoms  very  closely  resemble  those  of  cholera  in- 
fantum. The  disease  in  infants  should  be  diagnosticated  from  cholera 
infantum  by  finding  the  comma  bacillus  in  the  vomitus  or  in  the  dis- 
charges. There  are  no  especial  differences  between  cholera  Asiatica  in 
the  adult  and  the  same  disease  in  the  infant.  It  is  exceedingly  fatal  during 
infancy  and,  childhood,  and  young  infants  who  are  attacked  by  the  disease 


49(5  PEDIATRICS. 

during  a  cholera  epidemic  seldom  live.     The  treatment  is  the  same  as  that 
which  has  just  been  described  for  cholera  infantum. 

PERTUSSIS. 

Pertussis  (whooping-cough)  is  a  specific  infectious  disease,  highly 
contagious,  affecting  the  respiratory  tract,  characterized  by  periods  of 
spasmodic  coughing,  succeeded  by  a  prolonged  inspiration  and  accom- 
panied by  a  peculiar  sound  called  the  "  whoop.'' 

Etiology. — A  small  bacillus,  resembling  the  bacillus  of  influenza,  has 
been  found  almost  constantly  in  the  sputa.  The  experiments  of  Wollstein, 
in  obtaining  agglutination  of  this  organism  with  the  blood  of  patients  with 
pertussis,  point  to  a  causal  connection.  It  has  not  been  satisfactorily 
determined  whether  this  organism  is  the  bacillus  of  influenza  or  another 
organism,  and  its  identity  must  be  further  studied  before  it  can  be  regarded 
as  the  certain  specific  cause  of  the  disease. 

It  is  supposed  that  the  contagium  can  be  carried  by  a  third  individual, 
but  usually  it  is  directly  communicated  from  one  person  to  another. 
This  contagium  is  probably  contained  in  the  expectoration,  and  in  this 
way  the  disease  may  become  a  source  of  infection.  The  disease  com- 
monly occurs  in  epidemics  during  the  winter  and  spring.  Sporadic  cases 
occasionally  appear,  and  in  large  cities  the  disease  is  often  endemic.  Per- 
tussis seems  to  have  some  especial  relation  to  measles,  as  children  with 
the  latter  disease  are  liable  to  contract  pertussis,  and  in  like  manner  those 
with  pertussis  are  liable  to  contract  measles.  Children  with  pertussis  are 
also  especially  vulnerable  to  the  tulDercle  bacillus.  Pertussis  may  occur 
at  any  age,  but  it  is  especially  apt  to  attack  the  very  young  infant,  and  the 
disease  has  even  been  known  to  he  contracted  in  utero.  One  attack  usually 
protects  from  a  second.  Debilitated  children  with  catarrh  of  the  respira- 
tory tract  are  more  subject  tlian  others  to  the  contagium  of  pertussis. 

Incubation. — The  period  of  incubation  is  not  definitely  known,  but  is 
estimated  at  from  one  to  two  weeks.  The  disease  may  be  transmitted 
from  one  patient  to  another  from  the  beginning  of  the  catarrhal  symptoms. 

Pathological  Anatomy. — There  are  no  pathological  lesions  distinctive 
of  uncomplicated  pertussis.  The  condition  which  characterizes  the  parox- 
ysmal attacks  is  extreme  congestion  of  the  different  organs,  such  as  the 
meninges,  the  lungs,  the  heart,  and  the  kidneys.  In  grave  or  fatal  cases  the 
lesions  are  those  which  arise  either  from  mechanical  accidents,  as  emphy- 
sema or  hemorrhage  in  various  parts,  as  the  eye  or  the  meninges,  or  from 
such  complicating  diseases  as  broncho-pneLimonia  with  its  accompanyhig 
bronchitis  and  atelectasis.  The  bronchial  nodes  are  often  found  to  be  en- 
larged. An  examination  oftlie  blood  generally  shows  an  early  and  marked 
increase  in  the  white  corpuscles  in  which  the  lymphoid  cells  predominate. 

Symptoms. — It  is  customary  to  divide  the  disease  into  three  periods, — the 
eakir rial  stage,  the  sjxismodle  stage,  and  the  stage  of  dedine,  but  any  such 
differentiation  is  arbitrary  and  inexact,  as  all  three  periods  overlap  to  a 


SPECIFIC   INFECTIOUS   DISEASES.  497 

considerable  degree.  The  symptoms  in  the  beginning  and  often  for 
several  weeks,  are  simply  those  of  a  bronchial  catarrh  with  a  slight  rise 
of  temperature  and  a  cough  which,  although  sometimes  spasmodic,  is  often 
indistinguishable  from  that  of  an  ordinary  bronchitis.  After  a  period 
varying  from  a  few  days  to  two  or  three  weeks,  the  cough  becomes  more 
severe  and  of  a  more  decidedly  spasmodic  character,  and  the  peculiar 
whoop  which  characterizes  the  disease  appears.  The  cause  of  these 
paroxysms  seems  to  be  a  spasm  of  the  larynx.  This  is  accompanied  by 
a  feeling  of  suffocation.  The  paroxysm  begins  with  a  number  of  short, 
spasmodic,  expiratory  coughs,  succeeded  by  a  long-drawn  inspiration  and 
by  the  peculiar  whoop.  During  the  paroxysm,  especially  in  severe  cases, 
the  face  and  mucous  membranes  become  cyanotic,  the  eyes  protrude,  the 
conjunctivae  are  congested,  and  the  child  looks  as  though  it  would  die  of 
asphyxia.  After  a  few  seconds  the  child,  with  a  convulsive  cough,  expels 
some  tenacious  mucus,  and  is  then  relieved,  or  the  attack  returns  again, 
and  again  subsides,  and  the  symptoms  of  asphyxia  pass  away.  These 
paroxysms  are  often  followed  by  vomiting.  They  may  occur  only  four  or 
five  times  in  the  twenty-four  hours,  or  again  much  oftener, — at  times 
thirty,  forty,  or  fifty  times.  At  the  onset  of  the  attack  the  children  are 
usually  very  much  frightened,  and  either  run  to  the  mother  or  nurse  for 
aid,  or  go  to  some  part  of  the  room  where  they  can  be  undisturbed  during 
the  attack.  In  certain  children,  after  the  severe  paroxysms  have  lasted 
for  some  time,  a  small  ulcer  is  formed  on  the  frsenum  of  the  tongue,  from 
being  driven  against  the  edge  of  the  lower  teeth  during  the  paroxysms. 
During  the  course  of  the  paroxysmal  stage  of  pertussis  it  is  quite  common 
to  have  subconjunctival  hemorrhages  ;  rarely  deeper-seated  hemorrhages 
take  place  in  the  meninges  and  in  the  deeper  parts  of  the  eye.  In  pro- 
tracted cases  petechias  sometimes  appear  in  the  skin.  Epistaxis  may  also 
occur. 

Examinations  of  the  chest  during  the  attack  have  shown  that  the  pul- 
monary resonance  is  lessened  during  the  expiratory  stage  and  is  clear 
during  the  prolonged  inspiration.  The  auscultation  usually  shows  dimi- 
nution or  absence  of  the  respiratory  murmur.  Bronchial  rales  are  heard 
occasionally. 

Koplik  has  noticed  an  increase  in  the  area  of  the  relative  cardiac  dul- 
ness  duruig  the  paroxysmal  stage  of  pertussis,  which  is  often  accompanied 
by  a  slight  blowing  murmur  limited  to  the  apex  of  the  heart.  This  may 
well  occur  from  the  engorged  condition  of  the  right  side  of  the  heart, 
which  subjects  the  heart  to  a  great  strain  and  may  thus  result  in  dilata- 
tion. The  heart-sounds  are  apt  to  be  irregular  during  the  paroxysm,  and 
in  protracted  cases  during  the  intervals  the  pulse  is  often  irregular  and 
accelerated,  while  the  respirations  are  not  especially  hicreased  unless  some 
comphcation  has  arisen.  In  severe  cases  of  pertussis  the  kidneys  are 
sometimes  congested,  as  shown  by  the  appearance  in  the  urine  of  albumin, 

casts,  and  blood-cells.     Sugar  has  also  been  frequently  found.  • 

32 


498 


PEDIATRICS. 


After  the  disease  has  lasted  for  some  weeks  there  is  usually  a  certain 
amount  of  oedema  of  the  face,  especially  under  the  eyes.  The  paroxysms 
are  precipitated  by  nervous  excitement  or  by  an  irritation  in  the  throat  or 
the  respiratory  tract,  such  as  may  result  either  from  swallowing  or  from 
the  inhalation  of  dust.  The  stage  which  is  accompanied  by  the  whoop 
and  the  more  exaggerated  paroxysms  commonly  lasts  for  three  or  four 
weeks  or  even  longer.  The  paroxysms  then  become  less  severe,  and, 
although  the  cough  continues,  the  whoop  gradually  becomes  less  frequent, 
and  after  tliree  or  four  weeks  ceases  entirely.  AVhen  uncomplicated,  the 
duration  of  the  disease  is  usually  three  or  four  months.  Slight  changes 
in  the  atmosphere  or  exposure  will  give  rise  to  a  relapse.  The  relapses, 
however,  are  not,  as  a  rule,  of  a  severe  type,  and  in  these  cases  the  cough 
seems  to  arise  from  renewed  irritation  of  the  sensitive  mucous  membrane 
of  the  respiratory  tract  rather  than  from  a  fresh  infection  by  the  specific 
germ.  A  persistent  cough  follo^^■ing  an  attack  of  pertussis  may  sometimes 
be  caused  by  an  insidious  form  of  broncho-pneumonia. 

Fig.  115. 


Pertussis  during  paroxysm.    Female,  4  years  old. 


Fig.  115  represents  a  child  during  a  paroxysm  of  coughing  in  pertussis.  Slie  liad 
just  begun  to  cough,  had  become  decidedly  cyanotic,  and  was  aiding  the  expiratory 
effort  by  bending  forward  and  placing  her  hands  on  her  knees  at  the  moment  the  photo- 
graph was  taken. 


The  period  of  infection  is  supposed  to  last  for  a  certain  time  after  the 
whoop  has  ceased,  and  if  the  cough  continues  it  is  well  to  allow  for  a 


SPECIFIC    INFECTIOUS    DISEASES.  499 

period  of  infection  of  three  weeks  after  this  cessation.  It  is  possible, 
liowever,  that  the  whoop  may  occasionally  occur  for  long  periods  after 
the  child  has  ceased  to  be  a  source  of  infection  to  other  individuals. 

Complications. — The  complications  which  arise  in  pertussis  are  usually 
of  a  grave  nature.  The  dangers  from  hemorrhages,  unless  in  the  form  in 
which  they  occur  in  the  meninges,  are  not  great.  The  complication  of 
broncho-pneumonia  is  very  serious,  and  often  fatal.  The  especial  suscep- 
tiJDility  of  these  cases  to  the  development  of  some  form  of  tuberculosis, 
especially  a  tubercular  broncho-pneumonia,  renders  the  stage  of  con- 
valescence or  decline  one  which  demands  most  careful  observation. 
Severe  and  even  fatal  emphysema  may  occur  in  pertussis. 

Convulsions  may  arise  not  infrequently  in  infants  and  end  fatally. 
They  are  usually  caused  by  general  reflex  disturbance,  by  cerebral  con- 
gestion, or  by  some  cerebral  lesion.  Spasm  of  the  glottis  may  also  very 
rarely  cause  death  in  greatly  debilitated  children.  Excessive  and  obsti- 
nate vomiting  at  times  becomes  a  serious  complication,  and  may  reduce 
the  child's  strength  to  a  point  which  often  gives  rise  to  a  doubt  as  to  its 
recovery.  It  is  an  especially  grave  complication  in  infants  who  are  already 
much  debilitated.  Grave  intestinal  complications  are  liable  to  occur, 
especially  in  the  summer,  and  a  pronounced  atrophic  condition  is  not 
uncommon  when  the  disease  is  at  all  prolonged. 

Diagnosis. — The  diagnosis  of  pertussis  cannot,  as  a  rule,  be  made  until 
the  child  whoops.  Sometimes,  however,  Avhen  another  child  in  the 
family  has  undoubted  pertussis,  a  spasmodic  cough  may  allow  the  diag- 
nosis to  be  made  before  the  whoop  has  developed.  It  is  probable  that  a 
child  may  have  pertussis  without  at  any  time  developing  the  whoop.  In 
doubtful  cases  an  examination  of  the  blood  in  reference  to  the  presence 
of  an  increased  white  blood  count  consisting  largely  of  lymphocytes  may 
aid  in  making  the  diagnosis. 

In  some  children  a  simple  catarrhal  laryngitis  will  simulate  pertussis 
quite  closely ;  but,  although  in  these  cases  there  are  paroxysms  of  spas- 
modic coughing,  a  pronounced  whoop  does  not  occur,  and  the  symp- 
toms do  not  progressively  increase  and  last  for  a  long  period.  The  diag- 
nosis of  pertussis  can  usually  be  made  by  the  swollen  aspect  of  the  face, 
the  paroxysmal  cough  followed  by  the  expulsion  of  tough  mucus  and 
vomiting,  and  the  long  duration  of  the  attack. 

Prognosis. — Pertussis  is  a  very  serious  affection  in  young  infants,  and 
also  in  older  children  who  are  debilitated  or  poorly  cared  for.  When 
it  is  complicated  it  is  one  of  the  most  fatal  diseases  which  occur  in  early 
life.  When  it  occurs  in  older  children  the  prognosis  is  favorable,  pro- 
vided that  they  have  previously  been  well  and  strong,  that  they  are  well 
cared  for,  and  that  no  complications  arise. 

In  some  cases  young  infants,  if  their  vitality  is  unusually  good,  and  if 
they  are  carefully  nursed  and  made  to  take  a  sufficient  amount  of  food, 
show  remarkable  powers  of  resistance  during  attacks  of  pertussis. 


500  PEDIATRICS. 

A  case  of  this  kind  that  came  under  our  care  was  that  of  an  infant  five  months 
old.  In  March  she  suffered  from  an  attack  of  epidemic  influenza,  which  lasted  about 
twelve  days,  and  from  which  she  finally  recovered.  She  was  then  attacked  with 
measles,  and  after  the  temperature  had  fallen  to  the  normal  point  she  was  taken  with 
pertussis.  After  two  or  three  days  the  cough  increased  in  severity,  and  after  two 
weeks  the  infant  began  to  whoop.  The  attack  lasted  for  two  months,  and  she  finally 
recovered.  During  the  whole  course  of  the  disease  she  took  over  600  c.c.  (20  ouucos) 
of  modified  milk  in  the  twenty-four  hours,  and  for  a  short  time  small  doses  of  brandy 
were  given.  No  drugs  were  administei'ed.  The  temperature  varied  from  37.2°  to 
37.7°  C.  (99°  to  100°  F.). 

Prophylaxis. — Pertussis  is  so  highly  contagious  a  disease,  and  may  be 
so  serious  an  affection  in  certain  children,  that  a  rigid  prophylaxis  should 
be  enforced.  It  is  the  duty  of  those  who  take  care  of  children  with  per- 
tussis to  see  that  they  are  isolated  during  the  whole  course  of  the 
disease. 

Treatment. — In  the  treatment  of  pertussis  we  must  take  into  con- 
sideration the  age  of  the  individual,  the  stage  of  the  disease,  and  the  pres- 
ence or  absence  of  complications.  In  the  early  months  of  life,  after  the 
disease  lias  lasted  for  a  week  or  ten  days  and  has  become  more  severe, 
the  infant  will  usually  show  symptoms  of  general  circulatory  disturbance. 
The  great  strain  thrown  upon  the  heart  during  the  paroxysms  quickly 
affects  the  general  strength  of  the  infant,  a  marked  interference  with  its 
nutrition  soon  appears,  it  loses  in  weight,  and  often  refuses  its  food.  At 
times  it  will  become  somewhat  cyanotic  even  between  the  paroxysms,  and 
there  is  danger  not  only  from  the  severity  of  the  paroxysm,  but  also  from 
the  vitality  of  the  infant,  which  may  be  so  much  interfered  with  as  to 
prevent  its  recovery.  In  cases  of  this  kind  the  nursing  is  of  the  utmost 
importance.  The  infant  should  never  be  left  alone,  should  always  be 
taken  up  whenever  a  paroxysm  is  approaching,  and  should  be  assisted  in 
appropriate  ways  until  the  paroxysm  is  over.  Holding  the  infant  in  dif- 
ferent positions,  sometimes  bending  the  head  and  body  forward  at  the 
end  of  the  paroxysm  so  as  to  aid  by  gravity  the  expulsion  of  the  tenacious 
mucus,  is  desirable.  If  the  paroxysms  come  at  such  frequent  intervals  as 
to  threaten  the  Hfe  of  the  child  from  exhaustion,  intubation  may  be 
practiced,  as  suggested  by  O'Dwyer.  This  procedure  is  said  to  entirely 
overcome  the  spasm  of  the  glottis.  At  times,  also,  the  finger  covered  with 
a  thin  cotton  cloth  can  be  quickly  introduced  into  the  throat  and  the 
mucus  withdrawn  in  this  way.  It  is  of  the  utmost  importance  that  the 
infant  should  be  surrounded  continually  by  fresh  air.  For  this  purpose 
two  rooms  should  be  used,  if  possible,  one  of  which  should  have  all  the 
windows  thrown  wide  open,  so  that  the  air  can  be  completely  changed 
before  the  infant  is  brought  into  it,  and  the  patient  should  be  alternately 
taken  from  one  room  to  the  other,  the  temperature  of  the  rooms  being 
kept  as  equable  as  possible. 

The  nutrition  of  the  infant  is  so  easily  affected  that  the  utmost  atten- 
tion should  be  paid  to  the  administration  of  the  food.     Small  quantities 


SPECIFIC    INFECTIOUS   DISEASES.  501 

of  a  milk  carefully  modified  to  suit  its  digestion  should  be  given  at  frequent 
intervals,  preferably  after  the  occurrence  of  a  paroxysm,  as  it  is  then  more 
likely  to  retain  the  milk  in  its  stomach  a  sufficient  length  of  time  for  it  to 
be  absorbed  before  the  next  attack.  The  amount  of  food  which  the  infant 
retains  in  the  twenty-four  hours  is  an  important  factor  in  the  treatment. 
In  infants  of  from  six  to  twelve  months  at  least  600  to  750  c.c.  (20  to  25 
ounces)  of  milk  should  be  taken  and  retained  in  the  twenty-four  hours. 
When  the  amount  is  lessened  to  360  or  450  c.c.  (12  or  15  ounces),  the 
infant's  nutrition,  as  a  rule,  suffers  to  such  an  extent  that  unless  this 
amount  can  be  increased  a  fatal  issue  is  likely  to  result. 

Stimulants,  in  the  form  of  brandy  or  whiskey,  should  be  given  early  in 
the  attack.  When  the  cyanosis  is  a  prominent  feature  and  the  pulse  is 
irregular  and  intermitting,  small  doses  of  digitalis  should  be  given,  adapted 
to  the  age  of  the  child,  as  in  Table  58,  on  page  464.  In  these  cases, 
also,  the  administration  of  oxygen  is  a  valuable  adjunct  to  the  treatment. 
At  the  height  of  the  attack,  when  the  paroxysms  are  severe  and  espe- 
cially frequent  at  night,  the  burning  of  cresoline  in  the  room  at  night  is 
sometimes  beneficial.  If  burned  for  long  periods  the  urine  should  be 
watched  for  evidence  of  carbolic  acid  poisoning.  In  the  milder  forms  of 
the  disease,  which  are  not  accompanied  by  the  more  severe  symptoms 
just  enumerated,  belladonna  or  atropine  often  proves  valuable. 

There  is  no  drug  which  is  a  specific  for  pertussis  at  any  age.  The 
combination  of  antipyrin  with  sodium  bromide,  heroin  and  bromoform 
have  been  as  useful  as  any  drugs  which  we  have  had  experience  with. 
Antipyrin  may  be  given  in  0.065  gramme  (1  grain)  doses,  with  0.2  gramme 
(3  grains)  of  sodium  bromide,  every  three  hours,  to  an  infant  of  one  year. 
The  dose  of  antipyrin  may  be  doubled  for  a  child  of  three  years.  Heroin 
may  be  given,  0.0005  gramme  (j^o  grain)  every  three  hours,  to  an  infant 
under  one  year.  This  dose  may  be  raised  to  0.001  gramme  (-^^  grain)  at 
two  years,  and  to  0.002  gramme  (3V  grain)  at  5  years.  The  bromoform  is 
given  in  drops  on  sugar,  2  drops  for  an  infant  of  one  year,  and  3  to  4 
drops  at  three  years,  every  four  hours.  If  combined  with  liquids,  the 
bottle  should  always  be  thoroughly  shaken  before  using.  It  may  be  com- 
bined as  follows : 

PEESCRIPTIO^^    39. 

ApotJiecary. 


Metric. 

Gramma 

R     Bromoform 3j00 

Pelvis  acacici 6  00 

Oleum  amygd.  dulcis 20  00 

Aqua;  distil,  q.  s.  ad 12o|oo 


R     Bromoform ^^Ao 

Pelvis  acacici 3  iss 

Oleum  amygd.  dulcis 3  v 

Aquae  distil,  q.  s.  ad 5  iv 


lip  trp 

Sig.    ^  i  four  times  a  day  for  an  infant  of  one  year  ;    3  ii  for  a  child  of  3  years. 

For  older  children  whose  health  has  previously  been  good,  there  is  no 
especial  treatment,  except  that  they  should  have  as  much  fresh  air,  free  from 
dust,  as  possible,  and  that  food  be  given  them  after  they  have  vomited. 


502  J^EDIATRICS. 

AVhen  complications  arise,  the  treatment  is  that  of  the  complicating 
disease. 

In  cases  which  are  protracted,  a  change  of  air,  either  to  the  country  or 
to  the  sea-shore  at  suitable  seasons,  is  often  followed  by  an  apparent 
shortening  of  the  duration  of  the  attack. 

In  some  cases,  even  in  older  children  and  in  whom  no  complications 
are  present,  the  attack  of  pertussis  may  be  so  severe  as  to  prove  fatal. 
Northrup  reports  the  case  of  an  infant,  under  one  year  of  age,  who  died 
during  a  violent  paroxysm  in  pertussis,  and  in  Avhom  the  autopsy  showed 
extensive  vesicular  emphysema  with  great  distention  of  the  Avails  of  the 
alveoli.     The  following  case  occurred  in  our  practice  : 

A  boy,  six  years  old,  had  had  pertussis  for  five  -weeks.  For  two  weeks  previous 
to  our  seeing  him  the  cough  had  been  so  frequent  and  so  constantly  accompanied  by 
vomiting  that  the  child  had  been  unable  to  retain  any  food.  He  was  very  much  ema- 
ciated, and  was  so  weak  that  he  could  not  stand.  This  condition  lasted  for  a  week 
or  ten  days  :  he  then  began  to  improve,  and  finally  recovered  entirely.  There  were  no 
complications. 

ACUTE  INFECTIOUS  OSTEOMYELITIS. 

Acute  infectious  osteomyelitis  is  an  acute  arthritis  attended  by  sup- 
puration at  the  joints.  It  has  been  described  under  various  otiier 
names,  such  as  acute  arthritis  of  infants,  acute  jjurulent  synovitis  of  infants, 
acute  epiphysitis^  and  pycemia  of  the  hone. 

Etiology. — Nichols  has  shown  that  acute  infectious  osteomyelitis  is 
an  acute  inflammation  of  bone  due  to  any  one  of  a  number  of  patho- 
genic organisms,  hence  osteomyelitis  is  not  a  specific  disease,  but  belongs 
to  the  group  of  septic  pyaemias.  The  staphylococcus  pyogenes  aureus  is 
the  organism  that  most  commonly  produces  the  disease.  An  early  period 
of  development  and  the  exanthemata  predispose  to  osteomyelitis.  Trau- 
matism must  be  recognized  as  an  exciting  cause. 

Pathological  Anatomy. — In  infants  the  disease  commonly  originates 
~from  a  septic  infection  of  the  umbilicus  or  pharynx.  The  process  attacks 
the  bone-marrow  primarily,  and  the  joints  become  secondarily  involved  if 
the  process  originates  or  extends  to  the  end  of  the  bone  and  is  not  limited 
by  the  shaft.  The  joint  infection  may  come  either  from  separation  of 
the  epiphysis,  which  is  wholly  or  in  part  intra-capsular,  or  from  a  growth 
of  pyogenic  organisms  along  the  blood-  or  lymph-channels  of  the  epiphy- 
sis, frequently  setting  up  an  osteomyelitis  of  the  ossified  portion  of 
the  epiphysis  and  spreading  thence  into  the  joints.  The  two  affections, 
therefore,  ,  represent  different  phases  of  bone  infection,  rather  than 
different  diseases  of  the  bone.  The  morbid  process  sometimes  involves 
the  entire  structure  of  the  bone,  including  the  periosteum. 

Osteomyelitis  begins  as  a  hypersemia  of  the  bone-marrow.  Later, 
suppurative  foci  of  a  dull-yellow  or  grayish  color  appear,  while  in  severe 
cases  the  entire  marrow  becomes  purulent  and  the  Haversian  canals  of 


SPECIFIC    INFECTIOUS   DISEASES. 


503 


the  cortical  portion  become  filled  with  pus.  Metastatic  abscesses  and 
thrombosis  of  the  veins  of  the  marrow  may  follow.  When  the  infection 
enters  the  joint  the  cartilage  is  softened  and  destroyed  and  an  abscess  is 
formed.  Osteomyelitis  may,  however,  be  the  cause  not  only  of  a  sup- 
purative but  of  a  simple  inflammation  of  the  joint. 

Symptoms, — The  onset  is  sudden  and  sometimes  marked  by  a  chill. 
There  are  severe  constitutional  symptoms  of  fever  and  intense  pain 
usuahy  sharply  localized.  The  part  affected  is  swollen,  reddened,  and 
tender,  and  if  a  joint  itself  is  involved,  the  swelling  Avhich  is  at  first 
tense  soon  becomes  fluctuating.     From  the  beginning  of  the  disease  the 

Fig.   116. 


Case  of  osteomyelitis  of  the  radius,  the  radiograph  showing  a  marked  periosteal  thickening ;  as  well 
as  a  fairly  well  defined  focas  of  rarification  in  the  medulla  of  the  bone  itself.  The  extreme  proximal  end 
of  the  bone,  as  well  as  the  distal  epiphysis,  are  apparently  not  affected. 


signs  of  sepsis  are  manifest  by  the  high  intermittent  fever,  rapid  pulse, 
pronounced  leucocytosis,  and  great  prostration.  In  exceptional  cases 
these  severe  constitutional  symptoms  may  not  be  present.  In  rapid  cases 
death  may  occur  in  three  or  four  days,  but  the  disease  is  generally  pro- 
longed for  one  or  two  weeks. 

Diagnosis. — The  differential  diagnosis  is  to  be  made  chiefly  from  the 
articular  form  of  rheumatic  fever,  from  which  it  is  to  be  distinguished  by 


504  PEDIATRICS. 

the  surrounding  soft  parts  being  much  less  involved  and  the  general 
symptoms  much  more  severe  in  osteomyelitis,  and,  if  the  disease  occurs  in 
the  first  two  years,  by  the  rarity  of  rheumatism  at  so  early  a  period. 

From  tuberculosis,  osteomyeUtis  is  to  be  differentiated  by  the  slow 
onset  of  the  former  and  the  primary  lesion  generally  showing  itself  in  the 
shaft  of  the  bone  in  the  latter,  while  in  the  former  the  epiphysis  is  usually 
first  attacked.  The  process  of  osteomyelitis  may,  however,  attack  the 
epiphysis  and  extend  to  the  joint.  The  presence  of  a  leucocytosis  in 
osteomyelitis  is  also  of  great  aid  in  the  diagnosis. 

Prognosis. — The  prognosis  is  very  unfavorable  unless  immediate  and 
radical  surgical  interference  is  carried  out. 

Treatment. — The  treatment  is  essentially  surgical.  Where  osteomye- 
litis of  the  shaft  of  a  long  bone  is  found  at  operation,  all  of  the  affected 
portions  should  be  removed,  even  if  a  considerable  portion  of  the  shaft 
is  taken,  experience  having  shown  that  new  bone  will  soon  form,  and  that 
a  serviceable  limb  is  the  usual  result  in  the  leg  and  forearm. 

Prevention  of  septic  infection  of  the  umbilical  cord,  and  of  the  wound 
after  the  cord  has  fallen  off,  is  important  as  a  matter  of  prophylaxis. 

The  following  case  came  under  our  observation  at  the  Infants'  Hospital : 

An  infant,  one  month  old,  was  admitted  to  the  hospital  November  16.  The 
parents,  who  were  Italians,  were  seemingly  healthy  and  had  one  other  child,  a  girl, 
who  was  also  reported  to  be  healthy.  One  week  previous  to  entrance,  what  was 
described  as  a  "red  rash"  appeared  on  the  abdomen  and  spread  down  the  left  leg. 
It  lasted  about  four  days.  Two  nights  previous  to  entering  the  hospital  the  infant 
had  cried  seemingly  from  pain  on  movement  of  the  legs.  There  had  been  some  dis- 
charge of  pus  from  the  umbilicus  which  had  never  healed.  The  infant  appeared  to 
be  well  nourished  and  of  good  color,  with  no  abnormal  appearances,  excepting  that 
the  umbilicus  had  not  healed,  and  also  that  the  lower 'third  of  the  left  thigh  was 
swollen  so  as  to  be  twice  as  large  as  the  right  thigh,  and  that  the  skin  in  this  region 
was  red  and  shiny.  The  left  leg  was  held  stiffly  and  somewhat  flexed,  the  knee  being 
bent  almost  at  a  right  angle,  and  both  in  front  and  over  the  anterior  tibial  group  of 
muscles  and  over  the  calf  there  was  a  brawny  feeling  without  fluctuation  or  localized 
-  tenderness. 

On  the  day  following  entrance,  the  brawny  infiltration  was  less  extensive.  The 
temperature,  however,  remained  over  40°  C.  (104°  F.).  On  November  19,  a  vertical  in- 
cision was  made  from  the  inner  side  of  the  head  of  the  tibia  about  four  inches  down- 
ward. This  revealed  a  tibial  abscess  under  the  periosteum,  which  was  separated  for 
two  inches  both  in  front  and  behind.  The  cartilaginous  epiphysis  was  separated  and 
freely  movable,  and  the  bone  of  the  shaft  was  red,  rough,  soft,  and  covered  with  small 
bleeding  points.  The  upper  two  inches  of  the  shaft  were  removed,  revealing  what  ap- 
peared like  hard,  healthy  bone.  A  counter-opening  was  made  in  the  calf,  and  after 
irrigation  a  sterilized  dressing  was  applied.  The  temperature  continued  between  39° 
and  40°  C.  (102.2°  and  104°  F.). 

On  changing  the  dressing  in  the  afternoon,  the  lower  surface  of  the  upper  epiphys- 
eal cartilage  looked  gray  and  opaque,  but  at  the  next  dressing  several  bleeding  points 
were  seen  in  the  epiphysis  and  the  wound  looked  well.  A  swelling  had  suddenly 
appeared  over  both  malleoli,  and  an  incision  let  out  some  greenish  pus.  A  small  area 
of  the  bone  was  curetted  at  this  time. 

Some  hours  later  a  swelling  appeared  over  each  wrist,  which  was  drained  by  two 


PLATE   YI. 


Osteomyelitis  of  the  lower  end  of  the  femur,  with  spontaneous  fracture.  Boy,  9  years  old.  A,  lower 
end  of  upper  fragment ;  B,  upper  end  of  lower  fragment ;  C  and  D,  portions  of  cortical  bone  which  have 
been  sequestrated,  and  were  subsequently  removed  by  operation  ;  E,  callous  tissue. 


Tumor  albus  of  three  years  duration  in  a  girl  of  6)^  years.  The  destruction  of  bone  tissue  is  mainly 
confined  to  the  external  half  of  the  epiphysis  of  the  femur  and  to  the  adjacent  portions  of  the  diaphy^ 
sis.  A,  subcutaneous  cheesy  abscess,  communicating  with  the  diseased  area  of  the  bone  ;  B,  probably  a 
sequestrum  surrounded  by  necrotic  tissue  ;  C,  shows  enlargement  and  squaring  of  epiphysis  of  tibia,  as 
compared  with  the  normal,  indicating  congestion  and  proliferation  before  absorption  of  the  bone  tissue 
has  begun. 


SPECIFIC    INFECTIOUS   DISEASES.  505 

incisions,  one  over  each  styloid  process.  No  communication  was  found  witli  tlie  bare 
bone.  The  skin  was  found  to  pit  on  pressure,  and  to  be  slightly  reddened  over  the 
biceps. 

On  the  following  day,  November  22,  the  infant  was  found  to  be  jaundiced. 
Fluctuation  appeared  and  the  arm  was  freely  opened  from  the  coracoid  process  to  the 
elbow.  An  opening  was  also  made  at  the  posterior  border  of  the  deltoid,  as  pus  was 
discovered  along  the  long  head  of  the  biceps.  The  shoulder  was  then  irrigated  and 
drained. 

The  cultures  which  were  taken  from  each  of  these  abscesses  showed  no  growth 
excepting  the  one  from  the  tibia,  where  staphylococcus  aureus  was  found  in  abundance. 
It  was  afterwards  noted  that  this  growth  had  not  been  found  elsewhere  because  the 
oven  where  the  cultures  had  been  baked  had  been  overheated. 

On  the  following  morning  the  hand  and  arm  were  blue,  cold,  and  swollen.  No 
pulse  could  be  felt,  and  the  tissues  in  the  wound  were  almost  black.  The  child  died 
nine  days  after  the  first  symptom  pointing  to  an  affection  of  the  bone. 

The  autopsy  was  made  three  hours  after  death,  and  was  interesting  in  that  it 
showed  no  abscesses  which  could  not  be  traced  to  multiple  osteomyelitis.  There  was 
almost  entire  absence  of  pathological  changes  in  the  viscera.  A  separation  of  the 
epiphysis  had  occurred  at  the  lower  end  of  the  left  tibia  and  fibula,  the  upper  end  of 
the  left  femur,  the  lower  end  of  both  radii  and  ulnae,  and  the  upper  end  of  the  right 
humerus,  with  softening  of  the  bone  and  pus.  No  thrombi  were  found  in  the  right 
axillary  vessels,  the  whole  right  arm  to  the  wrist  being  swollen  and  discolored,  and  on 
cutting  into  it  a  red  serous  fluid  flowed  out  of  this  phlegmonous  inflammation.  Cul- 
tures from  the  heart's  blood,  kidneys,  and  liver  showed  no  growth,  but  from  the  hip- 
joint  and  tibial  marrow  there  was  an  abundance  of  pure  staphylococcus  aureus,  and 
from  the  phlegmonous  arm  a  faint  growth  of  streptococci.  Blood-serum  was  the  cul- 
ture medium. 

The  case  showed  a  rapid  septic  infection  confined  to  the  bone-marrow  and  bone  of 
the  shafts.  Several  long  bones  were  affected,  unaccompanied  by  any  inflammation  of 
the  lymphatic  glands  or  of  the  internal  organs. 

Pure  cultures  of  staphylococcus  aureus  were  obtained  from  the  left  tibia  and  hip, 
and  as  there  was  no  discernible  difference  in  the  appearance  of  the  three  bones,  it  is 
probable  that  the  same  micro-organisms  had  existed  in  all  the  inflamed  bones.  The 
streptococcus  infection  of  the  arm  was  probably  due  to  accidental  inoculation  at  the 
time  of  the  operation.  The  shoulder-  and  hip-joints  contained  pus,  but  the  knee  and 
wrist  escaped.  This  is  to  be  explained  by  the  anatomical  relation  of  the  epiphysis  to 
the  capsule  of  the  joint.  When  the  epiphyseal  line  reaches  within  the  joint-capsule  pus 
can  reach  the  joint  whenever  the  epiphysis  is  separated  by  suppuration,  and  this  rela- 
tionship existed  in  the  hip-  and  shoulder-joints.  In  the  wrist  the  capsule  is  inserted 
into  the  epiphysis  of  the  radius  and  ulna,  and  not  into  the  shaft,  so  that  pus  to  reach 
the  joint  has  to  perforate  the  cartilaginous  epiphysis.  This  is  more  difficult  than 
when  the  suppuration  can  pass  directly  from  the  epiphysis  into  the  joint.  The  same 
is  true  of  the  upper  epiphysis  of  the  tibia,  for  the  capsular  ligament  of  the  knee  does 
not  cross  the  epiphysis  but  is  inserted  into  it,  therefore,  when  separation  occurs,  the 
pus  burrows  under  the  pei'iosteum,  but  does  not  break  into  the  joint. 

RHEUMATIC  FEVER. 
Rheumatic  fever  is  a  disease  with  a  definite  clinical  picture,  mani- 
festing itself  chiefly  in  the  heart  and  joints.  Objections  to  the  terms 
^'  rheumatic  "  and  "  rheumatism  "  are  based  on  the  fact  that  these  terms 
have  been  applied  to  a  large  number  of  conditions  not  constituting  a 
definite  clinical  picture.     There  is,  however,  no  objection  to  their  use  if 


506  PEDIATRICS. 

they  are  limited  to  a  disease  which  has  either  a  specific  cause,  as  for 
example  typhoid  fever,  or  a  definite  clinical  and  anatomical  basis,  such  as 
scarlet  fever.  While  the  term  "  infectious  arthritis  "  is  properly  used  in 
describing  and  classifying  the  articular  manifestations  of  a  number  of 
infectious  diseases,  it  is  improper  to  use  the  term  "  infectious  arthritis  "  as 
synonymous  with  "  rheumatic  fever,''  since  rheumatic  fever  is  not  a  disease 
of  the  joints  alone.  The  articular  manifestations  of  rheumatic  fever, 
although  only  a  part  of  the  disease,  might  be  termed  one  form  of  infectious 
arthritis,  just  as  the  throat  symptoms  in  scarlet  fever  might  be  termed  one 
form  of  infectious  angina. 

The  term  "rheumatic  fever"  should  then  be  used  to  describe  the 
disease  in  all  its  characteristic  manifestations,  while  the  term  "  articular 
rheumatism  "  is  objectionable  as  implying  that  the  disease  is  primarily  one 
of  the  joints.  The  manifestations  of  rheumatic  fever  are  varied  and 
numerous,  some  of  them,  such  as  the  articular,  being  far  more  prominent 
in  the  later  periods  of  childhood  and  in  adult  life,  while  in  early  childhood 
up  to  the  fifth  and  even  eighth  year,  infection,  such  as  that  of  the  endocar- 
dium, is  much  more  common,  and  in  infancy  the  disease  is  comparatively 
rare.  In  a  series  of  223  consecutive  cases  of  rheumatic  fever,  collated  by 
Dunn,  at  the  Children's  Hospital,  Boston,  there  were  none  under  three 
years  of  age.  In  this  series  cardiac  lesions  occurred  in  92  per  cent,  of  the 
whole  series,  and  in  83  per  cent,  of  those  which  were  admitted  with  joint 
symptoms.  These  figures  do  not  represent  the  liability  to  cardiac  mani- 
festations in  the  general  run  of  cases,  as  they  were  based  upon  the  severer 
types  which  were  admitted  to  the  wards  of  the  Children's  Hospital. 
Cases  occasionally  occur  under  three  years  of  age. 

Etiology. — Of  the  various  views  which  have  been  held  concerning  the 
etiology  of  rheumatic  fever,  only  one  has  survived,  namely,  that  it  is  an 
infectious  disease,  and  that  its  cardiac  and  articular  lesions  are  manifesta- 
tions of  infection.  As  to  the  nature  of  the  infection  two  views  are  held ; 
(1)  That  rheumatic  fever  is  a  specific  infection  due  to  the  micrococcus 
rheumaticus,  (2)  That  rheumatic  fever  is  due  to  infection  with  a  variety  of 
organisms,  particularly  the  pyogenic  cocci,  infection  with  which  in  an 
attenuated  form  causes  the  characteristic  clinical  picture.  The  strepto- 
coccus group  has  been  especially  mentioned  in  connection  with  this  view. 
The  first  view  has  in  its  support  the  remarkable  definiteness  of  the  disease, 
which  suggests  a  specific  infection.  It  also  has  in  its  favor  much  experi- 
mental evidence  which,  however,  is  not  conclusive.  The  micrococcus  rheu- 
maticus, therefore,  has  not  been  absolutely  proven  to  be  a  specific  organ- 
ism. The  second  view  explains  the  remarkable  definiteness  of  the 
clinical  picture,  by  saying  that  rheumatic  fever  is  a  specific  reaction  of 
the  tissues  to  a  variety  of  infections.  The  experimental  work  in  support 
of  this  view  is,  however,  fully  as  inconclusive,  if  not  more  so,  than  that  in 
favor  of  the  first  view.  Neither  of  these  theories  can  be  accepted  without 
reservation. 


SPECIFIC   INFECTIOUS   DISEASES.  507 

It  seems  probable  that  the  usual  mode  of  mfection  is  through  the 
tonsils.  Recent  investigations  have  shown  that  a  large  number  of  cases 
were  shortly  preceded,  or  were  accompanied,  by  a  sore  throat.  There  is 
some  experimental  evidence  in  support  of  this  view.  Exposure  to  damp- 
ness, to  cold  and  to  sudden  and  great  changes  in  temperature  are 
important  predisposing  causes.     One  attack  predisposes  to  another. 

The  symptoms  are  varied  and  similar  to  those  of  an  infection,  as 
evidenced  by  the  character  of  the  fever,  the  involvement  of  the  serous 
membranes,  the  tendency  to  relapse,  the  sweats,  and  the  leucocytosis. 

Pathological  Anatomy. — The  particular  characteristic  of  the  lesions  is 
the  fact  that  the  inflammation  is  not  purulent.  The  serous  membranes 
are  especially  affected  and  the  prominent  lesions  are  those  of  the  joints, 
the  endocardium,  pericardium,  heart,  and,  in  rare  cases,  the  peritoneum, 
pleura,  and  pia  mater.  In  certain  cases,  especially  in  children,  and  much 
more  frecpently  met  with  in  England  than  in  America,  subcutaneous  fibrous 
nodules  are  found  attached  to  the  tendons  and  fasciae  in  any  part  of  the 
body  or  limbs.  The  affected  joints  show  hyperaemia  and  swelling  of  the 
synovial  membranes  and  of  the  ligamentous  tissues.  There  may  be  a 
slight  erosion  of  the  cartilage.  The  fluid  in  the  joint  is  albuminous  in 
character,  and  contains  leucocytes  and  a  few  fibrin  flakes.  An  extensive 
effusion  into  the  joint  is,  however,  uncommon.  The  lesions  of  the  endo- 
cardium are  described  on  page  736,  those  of  the  pericardium  on  page  754, 
and  those  of  the  myocardium  on  page  733.  The  blood  usually  contains 
an  excessive  amount  of  fibrin  and  shows  a  leucocytosis. 

Symptoms. — The  symptoms  of  rheumatic  fever  are  those  of  a  febrile 
disease,  represented  by-  a  variety  of  manifestations,  which  may  appear 
alone  or  in  groups,  but  are  all  dependent  on  a  primary  infection.  During 
the  first  two  years  of  life  rheumatic  fever  is  exceedingly  rare,  but  may 
occur.  Up  to  eight  years  of  age  the  type  of  the  disease  is  essentially 
different  from  that  of  the  adult.  There  may  be  slight  swelling  only,  and 
redness  and  tenderness  of  the  joints  may  be  entirely  absent  and  the 
temperature  only  slightly  elevated.  The  only  symptoms  are  likely  to  be 
stiffness  of  one  or  more  joints  with  pain  on  motion,  or  sometimes  with 
indefinite  wandering  pains  which  are  not  referred  to  the  joints.  In  these 
cases  with  obscure  symptoms,  the  hereditary  predisposition  to  rheumatic 
fever,  the  history  of  previous  attacks,  and  the  presence  of  endocarditis  or 
pericarditis  which  cannot  be  explained  on  other  grounds  are  important 
points  in  making  the  diagnosis. 

Articular  Manifestations. — The  onset  of  the  disease  in  children  above 
eight  years  of  age  is  usually  acute,  and  is  characterized  by  loss  of  appetite, 
fever,  swelling,  tenderness,  and  redness  of  one  or  more  joints.  Pro- 
nounced redness  and  swellingof  the  joints  are  not  so  marked  as  in  adults. 
The  temperature  and  pulse  are  usually  moderate,  although  in  the  begin- 
ning of  the  attack,  following  the  rule  of  acute  infectious  disease,  a  sudden 
rise  of  temperature  to  39.4°  to  40°  C.  (103°  to  104°  F.)  is  not  uncommon. 


608  PEDIATRICS. 

The  pulse  and  temperature  soon  fall  several  degrees  in  the  course  of  the 
disease,  and  then  gradually  become  normal,  unless  some  complication 
arises.  The  urine  is  diminished,  high-colored,  and  very  acid.  On  cooling 
it  deposits  urates.  The  chlorides  are  diminished.  A  characteristic  symp- 
tom is  profuse  and  acid  sweating,  having  a  sour  odor.  The  mind  is  usually 
clear.  The  joints  are  apt  to  be  invaded  successively,  the  joint  first  affected 
sometimes  becoming  decidedly  less  painful  and  swollen  as  the  next  joint 
is  involved.    Antemia  develops  rapidly,  and  leucocytosis  is  usually  marked. 

Cardiac  Manifestations. — By  far  the  most  frequent  infection  in  con- 
nection with  the  heart  is  endocarditis.  The  onset  of  endocarditis  is  usually 
characterized  by  rise  of  temperature,  and  either  precordial  pain  or  dys- 
pnoea, or  both.  On  physical  examination,  a  soft-blowing  systolic  murmur 
of  mitral  origin  is  heard.  Anaemia  is  usually  such  a  prominent  symptom 
in  rheumatic  fever  that  haemic  murmurs  may  arise  in  the  course  of  the 
disease  and  render  the  diagnosis  from  organic  murmurs  difficult.  An 
infection  of  the  endocardium  is,  however,  so  common  in  rheumatic  fever 
that  the  presence  of  a  murmur  should  be  looked  upon  as  a  possible  grave 
lesion  in  every  case,  and  the  heart  should  be  carefully  examined  at  each 
visit  for  the  purpose  of  detecting  any  abnormal  sound  as  soon  as  it  is  per- 
ceptible. In  some  cases  the  endocarditis  begins  very  insidiously  without 
noticeable  symptoms  referable-  to  the  heart,  and  in  children  there  is  a 
special  tendency  to  dilatation. 

Next  to  endocarditis  the  most  frequent  cardiac  manifestation  is  peri- 
carditis^  which  begins  with  a  pericardial  friction-rub,  usually  under  the 
middle  or  upper  part  of  the  sternum,  with  pain  and  precordial  distress^ 
and  later  with  the  usual  mechanical  symptoms  of  dyspnoea  and  orthop- 
noea,  as  described  under  pericarditis.  The  disease  is  often  associated  with 
endocarditis,  but  does  not  usually  occur  at  so  early  an  age  as  endocarditis, 
the  middle  period  of  childhood  being  most  prone  to  the  disease.  Especial 
mention  should  be  made  of  the  delirium  connected  with  pericarditis. 
When  a  pericarditis  is  accompanied  by  effusion,  the  fluid,  in  children,  is  as 
a  rule  not  purulent. 

Other  Manifestations. — Of  the  other  more  rare  manifestations  can  be 
mentioned  myocarditis,  pleuritis,  and  peritonitis,  also  certain  cerebral  com- 
plications usually  associated  with  hyperpyrexia  and  represented  by  delir- 
ium, coma,  and  convulsions.  The  relation  between  chorea  and  rheumatic 
fever  is  stated  on  page  933.  Various  forms  of  erythema  appear  in  the 
course  of  rheumatism.  The  small  subcutaneous  fibrous  nodules  already 
spoken  of  are  symptomatic  of  rheumatic  fever.  A  number  of  these 
nodules  may  appear  at  the  same  time  and  last  for  weeks  or  months. 

Diagnosis. — Any  case  of  acute  febrile  disease  accompanied  by  signs  of 
endocarditis,  or  by  pain  in  the  joints,  or  by  the  signs  of  pericarditis,  is 
presumably  a  case  of  rheumatic  fever,  unless  some  other  cause  can  be 
demonstrated.  In  some  cases  the  diagnosis  may  for  a  time  be  doubtful, 
but  it  should  be  remembered  that  absence  of  joint  symptoms  in  children  is 


SPECIFIC  INFECTIOUS   DISEASES.  5O9 

no  evidence  against  the  process  being  that  of  rheumatic  fever.  With  our 
present  behef  that  in  many  cases  the  infection  of  rlieumatic  fever  enters 
through  the  tonsils,  we  should  in  all  cases  where  the  manifestations  are 
doubtful,  carefully  inc{uire  as  to  a  previous  affection  of  the  throat.  We 
should  bear  in  mind  how  different  in  many  cases  are  the  symptoms  in  the 
young  from  the  pronounced  articular  symptoms  of  adults.  A  previous 
history  of  articular  attacks,  cardiac  symptoms  or  chorea,  is  strong  sup- 
porting evidence  of  rheumatic  fever,  owing  to  the  remarkable  tendency  to 
recurrent  attacks  in  early  life.  The  disease  is  to  be  differentiated  from 
several  affections  which  sometimes  resemble  it. 

From  Infantile  Scorbutus. — Symptoms  occurring  in  the  first  two  years 
of  life  should  be  carefully  distinguished  from  scorbutus  (page  337). 

From  Acute  Osteomyelitis. — The  diagnosis  is  made  principally  by  the 
greater  intensity  of  the  localizing  symptoms,  the  involvement  of  the  epiphy- 
ses or  the  shaft  of  the  bone,  rather  than  the  joint,  and  the  presence  of 
more  pronounced  constitutional  symptoms  in  osteomyelitis. 

From  Multiple  Secondary  Aiihritis. — Infections  of  the  joints  may  occur 
from  gonorrhoea,  scarlet  fever,  dysentery,  influenza,  cerebro-spinal  fever, 
and  a  number  of  infections,  but  the  differential  diagnosis  can  usually  be 
made  without  difficulty  by  the  course  of  the  symptoms,  the  tendency  to 
involve  but  one  joint,  and  the  recognition  of  the  disease  in  which  the 
arthritis  occurs. 

Prognosis. — When  the  joints  alone  are  involved  the  prognosis  is  in- 
variably favorable.  The  great  tendency  to  cardiac  involvement  and  to 
recurrences  should  be  remembered  and  makes  the  prognosis  more  grave 
than  is  usually  realized.  In  the  series  of  223  cases  above  spoken  of,  20 
per  cent,  died  while  in  -the  hospital  from  the  results  of  cardiac  involvement. 
Treatment. — The  child  should  be  kept  in  bed,  and  made  to  wear  soft 
flannel  night-gowns  so  fashioned  that  they  can  be  changed  with  as  little 
disturbance  as  possible,  and  fresh  gowns  should  be  put  on  as  often  as 
severe  sweats  occur.  It  is  desirable  that  patients  should  sleep  between 
blankets  in  preference  to  sheets.  Milk  is  beyond  doubt  the  most  appro- 
priate diet.  The  thirst  can  be  satisfied  by  lemonade,  or  oatmeal-  or  barley- 
water.     Soups  and  broths  may  be  used  to  vary  the  milk-diet. 

For  the  relief  of  pain,  however,  the  salicylates  are  especially  valuable. 
They  should  be  given  in  fairly  large  doses,  0.3  gramme  (5  grains),  for  the 
first  twenty-four  hours  until  toxic  symptoms,  such  as  slight  disturbance  in 
hearing  and  ringing  in  the  ears,  are  produced,  or  until  the  pain  has  sub- 
sided. When  the  pain  is  once  under  control,  small  doses  of  the  salicylates 
three  or  four  times  a  day  will  usually  keep  the  patient  comfortable.  With 
the  fresh  involvement  of  another  joint,  an  increase  in  the  c{uantity  of  the 
sahcylates  may  be  needed  temporarily.  Aspirin  and  the  ammonium 
salicylate  are  perhaps  the  most  useful  preparations.  Salol,  salicin,  and 
salacetin  may  be  tried.  The  doses  of  these  preparations  are  from  0.3  to 
0.6  gramme  (5  to  10  grains),  according  to  the  age,  three  times  a  day.    The 


510  PEDIATRICS. 

alkaline  treatment  is  often  effective,  and  may  advantag-eously  be  combined 
with  the  salicylates.  Ten  or  fifteen  grains  of  the  citrate  of  potassium  in 
two  or  three  ounces  of  water,  and  the  adcUtion  of  thirty  grains  of  bicarbo- 
nate of  soda  with  a  half-ounce  of  lemon-juice,  makes  an  agreeable 
effervescent  drink.  This  may  be  given  every  three  or  four  hours  until  the 
urine  is  slightly  alkaline,  and  then  in  such  quantities  as  to  keep  the  reac- 
tion just  perceptibly  alkaline. 

Phenacetine  in  small  doses,  0.06  to  0.12  gramme  (1  to  2  grains), 
guarded  with  stimulants,  may  be  used  to  control  exacerbations  of  pain 
when  it  is  not  desirable  to  increase  the  salicylates.  Especial  attention 
should  be  directed  to  the  heart,  and  its  complications  treated  syrnpto- 
matically. 

The  local  treatment  of  the  joints,  in  the  acute  stage,  consists  in  the 
application  of  hot  fomentations  for  the  relief  of  pain.  The  weight  of  the 
bedclothes  should  be  kept  off  the  aftected  .joiiiis  by  means  of  a  cradle. 
When  the  pain  has  subsided,  the  joints  should  be  wrapped  in  cotton-wool. 

Fig.  117. 


^jys^s^fe;'^*"'*'^ 


Rheumatic  fever.    Adult  type  of  disease.    Male,  33-0  years  old. 

When  the  process  has  become  subacute  or  chronic,  great  improvement,  as 
evidenced  by  diminution  in  the  swelling,  stiffness,  and  pain  on  motion, 
often  follows  the  application  of  dry  heat  for  an  hour  every  day  or  several 
times  a  week.  This  may  best  be  applied  by  the  ovens  especially  adapted 
for  the  purpose. 

The  use  of  salicylates  should  be  continued  in  smaller  doses  for  one  to. 
two  weeks  after  the  acute  symptoms  have  subsided,  as  exacerbations  are 
less  likely  to  occur. 

The  disease  will  generally  run  a  course  of  from  four  to  six  weeKS, 
during  which  time  the  patient  should  generally  be  kept  in  bed,  and  care 
be  taken  to  maintain  an  equal  temperature  in  the  room.  Owing  to 
the  tendency  to  a  recurrence  of  the  disease,  it  is  often  advisable  to  re- 
move the  child   to   a  Avarm,  drv  climate  during  the  cold  and  unsettled 


SPECIFIC    INFECTIOUS    DISEASES. 


511 


weather  which  prevails  in  the  Avinter  and  early  spring  in  the  north.  Gen- 
eral tonic  treatnfient  with  iron  and  nux  Tomica  should  be  carried  out  for 
several  weeks  after  the  subsidence  of  the  acute 
and  subacute  symptoms. 

The  following  case  illustrates  the  articular 
manifestations  of  rheumatic  fever  : 

A  boy,  three  years  and  four  mouths  old,  was  treated 
in  the  hospital  for  bronchitis,  and  when  convalescent 
from  that  disease  was  attacked  mth  rheumatic  fever. 

There  was  no  rheumatic  history  in  his  family,  and 
he  had  never  had  rheumatism  nor  any  other  disease 
except  bronchitis.  After  having  been  feverish  for  two 
days,  the  temperature  varying  from  37.7°  to  38.8°  0. 
(100°  to  102°  F.),  he  complained  of  pain  and  tender- 
ness in  his  shoulders,  wrists,  and  elbows.  On  the 
following  day  these  symptoms  increased,  being  es- 
pecially marked  in  the  left  hand  and  left  knee.  There 
was  an  expression  of  anxiety  on  his  face,  showing  that 
he  feared  the  tender  joints  would  be  touched.  The 
weight  of  the  bedclothes  was  kept  from  the  knee  by 
a  cradle,  aud  the  arm  was  comfortably  arranged  on 
a  pillow.  These  details  in  the  nursing  of  a  rheumatic 
child  are  very  important.  Fig.  117  shows  the  affected 
knees  and  wrist.  He  was  being  treated  with  oil  of 
gaultherium,  4  minims  every  three  hours.  The  tem- 
perature varied  from  38.3°  to  39.4°  C.  (101°  to  103° 
F.).  An  examination  of  the  cardiac  region  did  not 
reveal  any  cardiac  complication. 

The  child  suffered  considerably  for  four  weeks,  but  at  the  end  of  that  time  the 
joints  gradually  grew  less  painful,  and  he  was  entirely  well  thirty-three  days  from  the 
onset  of  the  attack. 


CHAKT 

19 

DAYS  OF  DISEASE                         J 

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Rheumatic  fever.  Acute  endo- 
carditis on  seventh  day  from  be- 
ginning of  a-ttact. 


The  following  case,  a  girl,  five  and  one-half  years  old.  was  interesting 
as  illustrating  a  number  of  characteristics  in  connection  with  the  rheumatic 
fever  of  children : 


She  was  attacked  eight  days  before  entering  the  hospital  with  pain,  swelling,  and 
tenderness  in  her  left  ankle.  On  entrance  her  temperature  was  40°  C.  (104°  F.).  her 
pulse  was  145,  and  her  respirations  were  40.  There  was  very  slight  pain  in  the  joints, 
and,  although  her  appetite  was  lessened,  she  otherwise  seemed  well,  and  had  not  com- 
plained of  any  pain  since  the  beginning  of  the  attack.  On  the  sixth  day  the  tempera- 
ture fell  to  37.2°  C.  (99°  F.).  It  is  interesting  to  note  the  extreme  latency  of  the  dis- 
ease, and  how  the  child  seemed  to  be  perfectly  comfortable  from  the  beginning  of  the 
attack,  except  when  the  ankles,  both  of  which  were  swollen  and  tender,  were  touched. 
On  the  seventh  day  of  the  disease  the  temperature  rose  to  38.6°  C.  (105.5°  F.),  and 
an  examination  of  the  chest  showed  a  mitral  systolic  murmur.  The  murmur  became 
more  marked,  and  was  transmitted  into  the  axilla  and  the  back.  The  area  of  superficial 
cardiac  dulne.-s  was  slightly  increased,  and  extended  to  the  middle  of  the  sternum. 

By  the  end  of  the  second  week  of  the  attack  the  pain  and  tenderness  had  left  the 
ankles,  and  the  child  seemed  quite  well.     The  area  of  superficial  cardiac  dulness  was 


514  PEDIATRICS. 

strong  woman,  who  had  always  been  perfectly  willing  to  give  any  information  required 
either  as  to  her  own  or  as  to  her  husband's  condition,  in  order  to  aid  in  the  preserva- 
tion of  her  infant's  life.  She  stated  that  she  had  never  had  any  miscarriages,  that  she 
was  perfectly  well  both  before  and  after  the  birth  of  this  infant,  and  that  she  had  never 
had  an  efflorescence  on  her  skin,  a  sore  throat,  nor  any  lesions  of  the  mucous  mem- 
branes. She  came  under  our  observation  when  her  infant  was  six  weeks  old,  and  has 
since  then  been  seen  sufEciently  often  for  us  to  say  that  so  far  as  we  can  determine  she 
has  had  no  symptoms  that  in  any  way  could  be  attributed  to  syphilis.  She  had  always 
had  a  plentiful  supply  of  breast-milk,  which  was  evidently  of  good  quality. 

A  syphilitic  infant  does  not  infect  its  mother  (CoZ/es's  Imo).  It  can 
infect  a  woman,  however,  who  either  has  never  had  syphihs  or  who 
has  never  given  birth  to  a  syphilitic  infant. 

It  is  probably  possible  for  a  syphilitic  foetus  to  infect  its  mother  in 
utero.  This  theory  of  retro-infection^  however,  has  not  been  universally 
accepted.  Fournier  believes  that  there  is  a  class  of  cases  in  which  the 
father  at  the  time  of  marriage  has  no  lesion  which  would  necessarily 
infect  the  mother,  where  the  mother  never  shows  any  initial  lesion  and 
remains  free  from  syphilis  so  long  as  she  is  unimpregnated,  and  where 
after  impregnation  she  becomes  sypliilitic  and  either  aborts  or  gives  birth 
to  a  syphilitic  infant.  In  connection  with  the  subject  of  retro-infection 
the  question  arises  whether  a  mother  who  becomes  syphilitic  during  her 
pregnancy  can  infect  the  foetus  (j^ost-conceptional  syj)hilis).  There  is  no 
doubt  that  she  may  abort  from  her  own  syphilitic  infection.  The  same 
authority  believes  that  the  foetus  is  also  syphilitic.  This  doctrine,  how- 
ever, is  not  universally  accepted.  There  is  no  doubt  but  that  infection 
may  take  place  ;  whether  it  always  does  is  not  yet  settled. 

It  has  been  found  that  when  a  woman  is  syphilitic  it  is  exceedingly 
common  for  her  to  abort.  Miscarriage  is  more  frequent  when  a  woman 
is  passing  through  the  early  stages  of  syphilis  than  later  when  she  has 
become  more  or  less  habituated  to  the  disease.  The  treatment  by  mer- 
cury in  these  cases  soon  after  impregnation,  and  continued  during  the 
pregnancy,  is  a  valuable  means  of  averting  abortion.  Although  the 
aborted  foetus  of  a  syphilitic  woman  is  usually  macerated,  yet  such  a 
condition  of  the  foetus  may  be  produced  by  other  diseases  as  well  as  by 
syphilis.  Birch-Hirschfeld  has  found  from  an  examination  of  a  large 
number  of  macerated  foetuses  that  seventy  per  cent,  were  undoubtedly 
sj'philitic. 

Although  the  tendency  to  transmit  the  disease  is  greatly  lessened  by 
time,  yet  the  thorough  treatment  of  the  parents  by  mercury  is  the  most 
efficient  means  of  preventing  such  transmission,  and  the  careful  use  of 
this  drug  in  proper  doses  is  never  contraindicated.  It  is,  therefore, 
evident  that  a  pregnant  syphilitic  woman  should  be  treated  with  mercury 
whether  she  was  infected  before  or  after  conception.  When  both  parents 
are  syphilitic,  and  when  their  syphilis  is  in  the  early  stages,  the  infant  is 
most  likely  to  inherit  the  disease,  and  under  like  conditions  the  disease  is 
apt  to  be  of  a  severe  type. 


SPECIFIC    INFECTIOUS  DISEASES.  515 

Infants  entirely  free, from  syphilis,  either  at  birth  or  later,  have  been 
known  to  be  born  of  parents  of  whom  one  or  both  were  undoubtedly 
syphilitic.     The  following  cases  illustrate  this  question  of  immunity  : 

Two  children  of  a  family  of  five  were  under  our  care,  all  of  whom  were  healthy  at 
birth  and  had  never  shown  any  symptoms  of  syphilis.  The  father  was  infected  with 
syphilis  before  marriage,  and  later  infected  his  wife.  They  were  both  carefully  treated 
with  mercury.  The  wife  had  never  had  any  abortions.  She  had  had  five  children, 
and  had  lost  none.  Both  father  and  mother  had  had  undoubted  secondary  and  ter- 
tiary lesions,  some  of  which  still  existed  at  the  time  we  saw  them. 

The  father  of  another  such  case  was  a  rag-sorter,  who  had  a  primary  syphilitic 
lesion  on  his  hand  twelve  years  previously.  The  lesion  was  followed  by  secondary 
symptoms.  He  had  never  had  any  lesion  on  the  penis.  While  he  was  being  treated 
his  wife  showed  symptoms  of  syphilis  and  was  also  treated  with  mercury.  This  child 
had  always  been  healthy,  and  was  one  of  three,  none  of  whom  had  ever  developed  any 
syphilitic  lesions. 

Pathological  Anatomy. — The  pathological  tissue-changes  which  take 
place  in  the  hereditary  form  of  syphilis  are  of  the  same  nature  as  those 
which  occur  in  the  acquired  form.  Diffuse  interstitial  hyj^erplasia  is  much 
more  common  in  the  hereditary  form  than  are  circumscribed  gummy 
tumors.  Changes  in  the  bones  are  very  common  in  hereditary  syphilis, 
and  in  fact  so  much  so  that  it  is  usually  considered  necessary  to  find  these 
osseous  changes  in  order  to  estai)lish  a  diagnosis  of  syphilis  in  the  foetus. 

Osseous  System. — The  changes  in  the  bones  which  take  place  in  heredi- 
tary syphilis  are  so  important,  not  only  on  account  of  their  pathological 
interest,  but  also  because  of  their  clinical  significance,  that  especial  atten- 
tion should  be  paid  to  them. 

In  this  connection  it  should  be  remembered  that  in  the  latter  part  of 
intra-uterine  life  the  long  bones  are  cartilaginous  and  the  process  of  ossi- 
fication is  intra-cartilaginous.  As  the  cartilage  changes  to  bone  the  carti- 
lage-cells increase  in  number  and  are  closely  crowded  together.  Then 
comes  the  area  of  osteoblasts,  then  the  calcareous  matter,  and  deeper 
down  in  the  ossified  portions  are  the  blood-vessels  running  in  from  the 
periosteum.  The  epiphyses  of  the  bones  of  the  arm  are  cartilaginous  at 
bu-th,  and  they  remain  separated  from  the  shaft  of  the  bone  for  some 
time  by  a  narrow  cartilaginous  layer.  It  is  in  this  cartilaginous  sepa- 
rating layer,  called  the  zone  of  proliferation,  represented  in  the  drawing 
of  a  normal  infant's  bone  (page  316,  Fig.  79  I.),  that  certain  changes  are 
found  in  hereditary  syphilis.  It  is  also  at  this  zone  of  proliferation  that 
the  growth  in  the  length  of  the  bone  takes  place,  and  it  is  here  that 
syphilitic  changes  are  most  often  found.  This  lesion  is  an  osteochondritis, 
and  may  occur  together  with  lesions  of  the  spleen  and  other  parts  of  the 
body,  or  as  the  only  manifestation  of  the  disease. 

Osteochondritis  is  ordinarily  the  form  of  bone-disease  in  infants. 
Osteoperiostitis  belongs  almost  exclusively  to  the  later  forms  of  heredi- 
tary syphilis  as  they  appear  in  older  children  and  in  young  adults. 


5  in  PEDIATRICS. 

The  bones  Avhich  are  affected  most  commonly  are  those  of  the  arms 
and  of  the  legs. 

Besides  these  common  osseous  lesions  a  morbid  condition  of  the 
fingers  and  toes,  called  iJaciylifis,  occurs  quite  frequently.  In  this  condi- 
tion the  fingers  and  toes  assume  a  peculiar  pyriform  shape.  In  addition 
to  these  purely  syphilitic  changes,  local  thinning  of  the  bones  of  the 
skull,  called  craniotabc.%  occasionally  occurs.  In  this  condition  the  bone- 
substance  is  absorbed,  leaving  only  the  integuments  and  membranes. 

Liver. — The  liver  is  always  lai^er  than  in  the  normal  condition.  The 
hepatic  tissue  is  harder  and  more  elastic  than  usual.  The  most  connnon 
cause  of  the  condition  is  a  diffuse  interstitial  nephritis.  In  other  cases 
the  enlargement  is  due  to  gummata.  The  liver  then  is  of  a  yellow  color, 
and  there  are  small  white  granulations  scattered  throughout  the  paren- 
chyma. The  hepatic  acini  under  normal  conditions  are  in  contact,  except 
at  the  prismatic  spaces  formed  by  their  union,  in  which  spaces  the  capsule 
of  Glisson  forms  an  envelope  to  the  afferent  portal  vessels  of  the  lobule. 
It  is  in  these  spaces  that  the  round  lymph-cells  form  and  collect  into 
small  nodules  representing  microscopic  gummata.  which  resemble  those 
that  occur  in  adults. 

Spleen. — Xext  fo  the  osseous  system  the  spleen  is  the  part  most  often 
affected  by  syphilis.  It  is  enlarged,  and  the  degree  of  splenic  enlargement 
is  usually  characteristic  of  the  severity  of  the  disease. 

Pancreas. — Birch-Hirschfeld  has  pointed  out  the  fact  thattlie  pancreas 
is  irequently  found  to  be  affected  in  hereditary  syphilis.  He  remarks 
that  the  interstitial  changes  which  he  found  in  the  pancreas  are  analogous 
to  those  which  occur  in  other  organs,  especially  the  liver,  and  that,  while 
these  changes  are  not  constant,  they  come  next  in  frequency  to  the  altera- 
tions in  the  spleen.  The  interference  with  the  function  ot  the  pancreas, 
which  mast  occur  when  it  is  diseased  to  any  great  extent,  is  probably  the 
cause  of  the  gastro-enteric  disturbances  so  common  in  hereditary  syphilis. 
Lvngf. — In  cases  of  hereditan*  sj'phiH.:  born  befoie  term,  and  in  those 
^  Ijorn  at  term  who  live  but  a  few  days,  the  lungs  present  certam  patho- 
logical conditions  represented  by  nodules  or  small  tumors,  usually  super- 
ficial and  varying  in  size.  Sometimes  an  entire  lobe  may  be  involved, 
and  the  dense,  altered  lung-tissue  is  colorless  gray  or  white,  both  on  its 
surface  and  on  its  section.  This  condition  has  been  called  by  Virchow 
jmeumonia  alba.,  white  hepatization. 

Kidney  and  Testicle. — The  kidney  and  testicle  may  show  the  lesions 
of  syphilis.  It  is  to  be  noted  that  the  lesions  of  these  organs  are  amenable 
to  treatment.  The  disease  in  the  testicle  is  represented  by  a  gradual 
enlargement,  and  is  usually  bilateral. 

Throat,  Upper  Air-Passages,  Thymus  Gland,  and  Head. — Extensive 
lesions  are  at  tmies  found  in  connection  with  the  phan'nx,  larynx,  trachea, 
and  neighboring  parts,  and  also  with  the  thymus  gland  and  ^^ith  the 
muscles  of  the  heart. 


SPECIFIC    INFECTIOUS    DISEASES.  517 

Early  Manifestations  of  Hereditary  Syphilis. — Symptom^  and  Patho- 
logical Anatomy. — The  severity  of  the  disease  determines  the  type  of  the 
efflorescence,  and  is  also  influenced  by  the  time  when  the  infection  of  the 
foetus  took  place.  Thus,  the  later  the  period  of  infection  the  milder  will  be 
the  form  of  the  efflorescence  which  first  appears,  while  the  less  severe  the 
general  symptoms  the  better  will  be  the  prognosis  and  the  greater  the 
amenity  of  the  disease  to  treatment.  The  reverse  of  these  rules  is  found 
when  the  infection  has  taken  place  early,  and  when,  as  a  result,  the  infant  is 
born  dead,  or  at  birth  shows  such  advanced  stages  of  the  disease  as  are 
represented  by  the  more  intractable  forms  of  efflorescence  and  severe 
general  symptoms,  making  the  prognosis  exceedingly  grave. 

In  the  mfld  form  of  the  disease  the  infant  may  be  born  apparently 
healthy  and  may  show  no  indications  of  its  syphilitic  inheritance  for 
some  weeks.  It  is  rare,  however,  for  the  symptoms  to  be  delayed  beyond 
the  first  three  or  four  months  of  life.  The  earliest  symptoms  of  heredi- 
tary syphilis  correspond  to  the  secondary  symptoms  of  acquired  syphilis. 
Commonly,  unless  the  infant  is  born  with  the  efflorescence,  it  is  noticed 
at  birth,  or  within  two  or  three  weeks,  to  have  occlusion  of  the  nares 
{snuffl-eh),  and,  soon  after,  a  hoarse  cry  and  an  efflorescence  of  a  macular 
or  a  popular  variety.  The  efflorescence  is  general,  includes  the  palms 
of  the  hands  and  the  soles  of  the  feet,  and  is  especially  prominent  on  the 
forehead. 

The  condition  of  the  infant  depends  considerably  on  that  of  the 
mother.  The  rule  is  that  these  infants  when  born  are  emaciated,  but  we 
have  seen  them  well  developed  and  apparently  in  good  condition.  The 
disease,  with  appropriate  treatment  and  good  feeding,  may  in  some  cases 
be  arrested  in  this  stage,  and  be  cured  so  that  it  will  not  return,  or  it 
may  advance  to  another  group  of  symptoms,  which  are  represented  by 
lesions  of  the  mucous  membranes,  and  sometimes  by  pseudo-paralysis 
of  one  or  both  limbs  of  a  greater  or  less  degree.  All  these  symptoms 
may  arise,  run  their  course,  and  completely  disappear,  sometimes  never 
to  return.  Again,  they  may  reappear  at  various  times  during  the  indi- 
vidual's life,  but  they  are  especially  liable  to  recur  during  the  middle 
period  of  childhood  and  at  puberty. 

The  course  of  syphilis  is  so  influenced  by  treatment  that  the  symp- 
toms must  necessarily  be  irregular.  When  the  disease  is  untreated,  as  a 
rule,  all  the  symptoms  grow  worse.  The  infant  becomes  more  and 
more  emaciated,  and  either  it  dies  in  a  few  weeks  of  inanition,  or  the 
disease  progresses  still  further  and  serious  lesions  of  the  various  organs, 
such  as  the  lung,  liver,  spleen,  and  kidney,  may  finally  produce  a  fatal 
result. 

Efflorescence. — V^e  can  judge  to  a  great  degree  as  to  the  severity  of 
the  disease  by  the  type  of  the  efflorescence,  and  also  by  the  time  when 
it  occurs  after  birth.  The  mildest  and  most  benign  form  of  syphilitic 
efflorescence  is  represented  by  maculce^  the  next  by  jyapulai,  and  the  next 


518  PEDIATRICS. 

hj  pustulce  and  buUce.  Another  form  of  efflorescence  simulating  psona^/^ 
is  one  of  the  more  severe  manifestations  of  syphilis,  as  is  also  that  form 
which  is  called  riq)ia,  where  the  efflorescence  consists  of  thick  layers  of 
crusts  arranged  one  above  the  other,  formmg  a  conical  mass,  the  skin  at 
the  base  being  somewhat  infiltrated.  All  of  these  types  of  the  disease  have 
been  known  to  be  cured.  Finally,  one  ^^ill  meet  at  times  with  a  very 
dangerous  form  of  the  disease,  which  is  almost  uniformly  fatal  no  matter 
what  the  treatment  may  be.  This  is  what  is  called  syphilitic  pemphigus^ 
and  is  represented  by  large  and  numerous  bullte.  The  syphilitic  efflores- 
cences, unlike  most  other  lesions  of  the  skin,  appear  commonly  on  the 
palms  of  the  hands  and  the  soles  of  the  feet. 

Alopecia. — In  addition  to  these  general  symptoms  there  occurs  in  the 
hereditary  form  of  syphilis  the  loss  of  hair  which  is  so  common  in  the 
acquired  form  of  the  disease.  This  alopecia  may  be  caused  by  any  of 
the  dermal  lesions  which  occur  during  the  course  of  the  disease,  but  is 
probably  due  mostly  to  the  general  lack  of  nutrition  in  which  the  skin 
participates  with  the  other  organs  of  the  body  in  syphilis.  In  certain 
cases  the  eyebrows  and  eyelashes  are  lost,  and  Barlow  believes  that  the 
former  condition  is  characteristic  of  the  disease,  or  at  least  should  excite 
a  suspicion  of  its  presence. 

Lymph-Nodes. — Enlargement  of  the  lymph-nodes,  adenopathy,  seems 
to  be  less  marked  in  hereditary  syphilis  than  in  the  acquired  form.  This 
enlargement  may  be  due  to  reflex  irritation  from  the  more  severe  dermal 
lesions,  but  in  certain  cases  it  is  found  where  no  dermal  lesion  exists. 
The  enlarged  nodes  may  be  in  the  inguinal,  the  axillary,  or  the  cervico- 
maxillary  regions.  They  are  distmct,  movable,  multiple,  and  non-inflam- 
matory. The  older  the  child  the  more  likely  the  glands  are  to  be  en- 
larged. 

Nails. — According  to  Post,  the  nails  are  involved  quite  frequently  in 
hereditary  syphilis,  and  more  frequently  than  in  the  sj^hilis  of  the  adult. 
The  onychia  occurs  in  two  forms.  In  the  first  form  a  papule  or  pustule 
^^-appears  on  the  skin  at  the  side  of  the  nail.  This  ulcerates  and  extends" 
along  the  side  of  the  nail,  at  times  involvmg  the  matrix  and  causing  the 
loss  of  the  nail.  The  thick  and  everted  edges  of  the  ulcer,  its  sloughing 
base  and  sanious  discharge,  are  somewhat  characteristic,  and  are  accom- 
panied by  a  painful  enlargement  of  the  distal  phalanx.  (For  another 
form  of  onychia,  see  page  531.)- 

Teeth. — The  effect  of  hereditary  syphilis  on  dentition  is  quite  marked. 
The  first  teeth  instead  of  bemg  cut  in  the  sixth  or  seventh  month  may 
not  appear  until  the  fourteenth  or  fifteenth  month,  and  sometimes  even 
later.  These  primary  teeth  are  especially  liable  to  decay  early.  There 
is  nothing  sufficiently  characteristic  to  be  of  diagnostic  value  in  the  ap- 
pearance of  the  teeth  of  the  first  dentition. 

Eye. — Hutchinson  has  observed  twenty-three  cases  of  iritis  m  sj^hi- 
litic  infants.     The  average  age  for  the  beginning  of  the  iritis  was  five 


SPECIFIC   INFECTIOUS   DISEASES.  519 

and  a  half  months.  The  oldest  was  sixteen  months  at  the  time  of  the 
outbreak,  the  youngest  six  months.  Both  eyes  were  affected  in  eleven 
cases,  and  in  fifteen  cases  the  effusion  of  lymph  was  copious.  The 
cornea  was  affected  in  a  few  cases.  In  seven  cases  the  cure  was  com- 
plete, in  twelve  the  pupil  was  partially  occluded.  Iritis  is  one  of  the 
rarest  of  the  symptoms  of  hereditary  syphilis,  and  at  times  escapes  notice 
on  account  of  the  very  slight  symptoms  which  usually  attend  it.  The 
diagnosis  in  these  cases  is  not  dependent  on  the  iritis  alone,  but  the 
infants  always  show  other  well-marked  symptoms  of  syphilis.  There  is 
great  danger  of  the  disease  resulting  in  blindness  if  it  is  left  untreated, 
and  mercurial  treatment  is  most  efficient  in  effecting  a  cure. 

Digestive  Organs. — In  regard  to  the  digestive  disturbances  which  arise 
in  these  cases  of  hereditan,'  syphilis,  it  is  well  to  remember  that  they  may 
depend  upon  a  syphilitic  lesion  of  the  liver,  spleen,  and  pancreas,  as  well 
as  of  the  stomach  and  intestines.  It  is,  therefore,  necessary  to  treat 
these  disturbances  of  the  gastro-enteric  tract  in  a  different  manner  from 
what  is  customarj^  where  a  local  non-syphilitic  cause  is  supposed  to  be 
present.  In  fact,  mercurial  treatment  mil  produce  the  best  results  in 
these  cases. 

Hemorrhages. — An  affection  called  syphilis  hcemorrhagica  neonatorum  is 
met  with  at  times.  Bumstead  and  Taylor  have  reported  two  cases  of 
this  kind,  and  state  that  the  disease  is  rare,  less  than  twenty  cases  having 
been  noted.  The  hemorrhages  vary  in  their  extent,  and  may  occur  in 
either  the  skin  or  the  mucous  membranes.  This  class  of  cases  is  difficult 
to  differentiate  from  the  hemorrhagic  disease  of  the  new-born  which 
has  been  described.  There  is  no  doubt  that  syphilis  has  in  a  number 
of  cases  an  etiological  significance  in  the  umbilical  hemorrhage  which 
occurs  in  the  early  days  of  life.  Dr.  Uracek  has  reported  a  series  of 
hemorrhages  in  the  different  internal  organs  apparently  depending  upon 
a  syphilitic  taint  in  the  infant. 

Nose. — ^The  occlusion  of  the  nares  may  increase  to  such  a  degree  that 
the  breathing  of  the  infant  is  seriously  interfered  with,  and,  without  any 
other  s)T3hilitic  lesion,  it  may  die  from  imperfect  oxygenation  of  the  air 
which  enters  its  lungs. 

This  occlusion  of  the  nares  may  cause  great  loss  of  sleep.  We  must, 
however,  understand  that,  even  where  this  lesion  is  not  of  any  great  ex- 
tent, syphilitic  infants  suffer  from  insomnia.  This  insomnia  is  usually 
accompanied  by  cr\ing,  so  that  it  is  probable  that  the  restlessness  and  in- 
somnia are  due  to  pain  in  the  bones,  as  these  symptoms  are  often  present 
where  there  is  no  digestive  disturbance.  In  connection  with  these  syphi- 
litic lesions  of  the  nose,  flattening  of  the  bridge  of  the  nose  is  at  times  a 
noticeable  symptom. 

Anus. — There  is  nothing  especial  to  describe  concernmg  the  condylo- 
mata which  are  found  in  the  anal  region  and  which  are  rare  in  compari- 
son with  the  lesions  of  the  mouth.    They  begin  as  rounded  papules,  which 


520  PEDIATKICS. 

sometimes  coalesce,  and  there  is  more  or  less  infiltration  of  their  edges 
and  breaking  down  of  their  centres. 

Mouth. — The  syphilitic  lesions  of  the  mouth  are  fomid  so  commonly, 
and  are  of  so  important  a  character,  that  an  especial  description  should 
be  given  of  them.  There  is  no  syphilitic  lesion  of  the  mouth  which  is 
represented  by  a  characteristic  stomatitis.  The  mucous  membrane  in  the 
course  of  hereditary  syphilis  may  at  any  time  be  in  so  sensitive  a  condi- 
tion that  the  various  forms  of  stomatitis  may  be  engrafted  on  it,  and  we 
thus  may  have  different  lesions  of  the  lips,  tongue,  buccal  cavity,  and 
tonsils,  which,  while  simply  representing  the  lesions  of  certain  non-syphi- 
litic affections,  may,  by  their  peculiar  grouping  in  combination  with  other 
symptoms,  represent  the  hereditary  form  of  syphilis.  The  lesions  most 
commonly  appear  around  the  lips  and  on  the  mucous  membrane  lining 
the  cheeks.  On  the  lips  fissures  are  exceedingly  frequent ;  on  the  upper 
lip  they  commonly  appear  on  either  side  of  the  median  lobule,  while  on 
the  lower  lip  they  are  usually  single  and  in  the  median  line.  The  angle 
of  the  mouth  is  often  the  seat  of  condylomata,  and  these  are  frequently 
covered  with  crusts  and  at  times  are  deeply  ulcerated.  A  peculiar  appear- 
ance is  in  some  cases  seen  at  the  commissures  of  the  mouth,  caused  by 
cutaneous  ulcerations,  which  make  it  look  larger  than  normal,  and  at 
times  produce  a  number  of  lines  radiating  from  the  mouth  to  the  cheeks. 
Ulcerations  may  occur  on  the  tongue,  the  lips,  and  the  fauces.  Forch- 
heimer  considers  that  the  fissures  which  occur  in  syphilitic  infants'  mouths 
when  they  are  present,  leave  no  doubt  as  to  the  diagnosis,  since  they  are 
infiltrated.  The  most  common  place  for  them  to  appear  is  at  the  corner 
of  the  mouth.  In  this  place,  as  a  rule,  the  most  striking  feature  of  the 
fissure  is  that  it  is  a  papule  which  has  been  split  in  or  about  its  middle, 
and  that  it  has  an  infiltrated  edge.  The  fissures  sometimes  disappear  in 
the  mucous  membrane,  sometimes  stop  before  reaching  it,  and  sometimes 
run  into  it.  The  fissures  may  or  may  not  be  covered  by  a  crust,  and, 
unlike  most  syphilitic  efflorescences,  produce  more  or  less  pain  when  the 
^-^Houth  is  opened.  These  fissures  are  called  rhagades.  They  are  charac- 
terized by  their  persistency  and  by  their  lack  of  tendency  to  spontaneous 
healing.  Ulcers  and  'plaques  muqueuses  may  be  found  upon  the  mucous 
membrane  of  the  lips  and  cheeks  and  on  the  sides  and  under  surface  of 
the  tongue.  They  are  superficial,  but  cover  more  space  than  the  fissures. 
The  infiltration  is  not  so  well  marked,  but  is  present  to  a  greater  or  less 
degree.  The  most  common  lesions  which  are  found  on  the  tongue  are 
these  plaques  muqueuses  and  ulcers.  Both  have  infiltrated  edges,  but 
the  plaque  in  this  situation  rises  above  the  level  of  the  tongue,  while  the 
ulcerations  are  considerably  depressed.  They  are  both  characteristic  of 
syphilis.  Their  locality  is  determined  somewhat  by  the  presence  of  such 
irritants  as  sharp  teetli  pressing  agamst  a  portion  of  the  tongue.  The 
secretion  of  all  these  lesions  of  the  mouth  and  lips  is  highly  infectious. 
Bones. — One  of  the  striking  symptoms  of  this  early  stage  of  heredi- 


SPECIFIC    INFECTIOUS    DISEASES.  521 

tary  syphilis  results  from  osteochondritis.  According  to  Post,  the  form 
of  lesion  is  usually  that  of  a  tumor  at  the  junction  of  the  diaphysis  and 
epiphysis  at  the  distal  end  of  the  long  bones,  although  any  part  of  the 
osseous  system  may  be  involved.  These  swellings  are  difficult  to  recog- 
nize in  fat  children.  The  tumors  rise  abruptly  from  the  bones  ;  they  are 
small  and  globular,  and  in  some  cases  form  a  ring  at  the  junction  of  the 
shaft  and  epiphysis  ;  in  others  the  whole  epiphysis  is  enlarged.  At  times 
only  a  part  of  the  cartilage  is  affected,  and  the  external  swelling  is  corre- 
spondingly circumscribed.  The  lesions  appear  soon  after  birth,  and  their 
development  is  completed  either  slowly  or  rapidly.  The  termination 
varies  widely.  The  swelling  may  be  absorbed  under  appropriate  treat- 
ment, or  suppuration  may  take  place  and  the  skin  break  down ;  the  dis- 
ease may  end  in  the  separation  and  destruction  of  the  epiphysis.  The 
result  upon  the  iinal  growth  of  the  bone  varies,  of  course,  with  the 
severity  of  the  local  disease.  When  the  morbid  process  is  arrested  before 
the  destruction  of  either  cartilage  or  epiphysis,  there  is  no  deformity,  but 
the  destruction  of  cartilage  puts  an  end  to  growth  at  that  point,  and 
a  more  or  less  shortened  and  useless  limb  results.  When  the  disease 
takes  such  a  course  as  to  separate  the  epiphysis  while  the  integuments 
remain  sound,  the  limb  becomes  useless  for  a  time  and  appears  to  be 
paralyzed.  The  disease  was  first  fully  described  by  Parrot,  and  is  known 
as  Parrot's  disease,  or  sypliilitic  pseudo-paralysis  of  the  new-born.  The 
joints  in  immediate  connection,  with  the  diseased  bones  are  sometimes  in- 
volved. There  may  be  simply  an  effusion,  but,  where  the  bone  is  de- 
stroyed, serious  disorganization  of  the  joint  must  follow.  The  pain  and 
sensitiveness  in  these  cases  of  pseudo-paralysis  are  probably  caused  by  a 
low  grade  of  periostitis. 

The  bones  of  the  fingers  and  of  the  toes  present  at  times  the  pecu- 
liar lesion  which  is  known  as  dactylitis  syphilitica.  The  phalanx  may  be 
enlarged  to  two  or  three  times  its  natural  size,  giving  the  fingers  a  pyri- 
form  shape.  One  or  several  fingers  or  toes  may  be  involved,  and  some- 
times the  metacarpal  bones  are  diseased.  The  proximal  phalanx  is  more 
frequently  affected  than  the  distal  phalanx.  In  the  early  stages  the  integu- 
ment is  unchanged ;  later,  the  overlying  parts  become  involved  and 
abscesses  form.  If  the  case  is  submitted  to  early  treatment  the  deformity 
usually  subsides,  but  if  untreated  the  disease  may  result  in  permanent 
deformity  and  uselessness.  Dactylitis,  however,  is  not  characteristic  of 
syphilis  alone,  as  it  occurs  also  as  a  result  of  tubercular  disease  of  the 
bone. 

One  of  the  more  uncommon  symptoms  of  hereditary  syphilis  is  cranio- 
tabes,  but  in  rare  cases  it  may  be  found.  These  softened  spots,  nearly 
circular  in  form  and  about  1.2  cm.  (h  inch),  more  or  less,  in  diameter, 
may  be  recognized  by  the  finger  during  life.  Formerly  craniotabes  was 
considered  to  be  exclusively  a  symptom  of  rhachitis.  It  is  found 
especially  in  the  occiput.     It  is  present  in  rhachitis  where  no  trace  of 


522  PEDIATRICS. 

syphilis  can  be  discovered,  but  it  seems  to  be  most  common  in  cases  in 
which  there  is  a  distinct  syphilitic  taint.  Out  of  one  hundred  cases  of 
craniotabes  collected  by  Drs.  Barlow  and  Lees,  in  forty-seven  there  was 
satisfactory  proof  of  syphilis. 

Diagnosis. — The  diagnosis  of  hereditary  syphilis  in  its  more  advanced 
forms,  such  as  has  just  been  described,  is  not  difficult,  as  no  other  disease 
represents  such  serious  lesions  of  the  skin  with  such  a  combination  of 
general  symptoms  and  lesions  of  the  mucous  membranes. 

The  milder  forms  of  the  disease  are  frequently  mistaken  for  other 
diseases  of  the  skin,  such  as  papular  erythema,  which  simulate  the  syphi- 
litic lesions  but  which  are  of  a  benign  character. 

Occlusion  of  the  nares  caused  by  swelling  of  the  Schneiderian  mem- 
brane, if  persistent  during  the  early  weeks  and  months  of  life  without  rise 
of  temperature,  should  always  make  us  suspicious  of  the  presence  of 
hereditary  syphilis,  for  a  syphilitic  efflorescence  is  often  so  slight  and  eva- 
nescent as  to  be  frequently  overlooked. 

Marked  improvement  following  the  administration  of  mercury  is  also 
usually  considered  of  diagnostic  value,  and,  although  not  by  any  means 
conclusive,  is  at  least  significant. 

Periostitis,  especially  of  the  lower  end  of  the  humerus  or  the  anterior 
border  of  the  tibia,  is  met  with  in  children.  It  should  make  us  suspicious 
that  syphilis  is  causing  this  condition,  especially  if  there  is  periostitis  of  a 
number  of  bones  at  once. 

A  great  deal  has  been  written  and  much  discussion  has  taken  place 
regarding  the  relationship  between  syphilis  and  rhachitis.  The  two  dis- 
eases are  so  distinctly  separated  that  it  seems  scarcely  necessary  to  dwell, 
except  very  briefly,  on  the  differential  diagnosis  between  them.  Rha- 
chitis is  so  largely  dependent  in  its  osseous  changes  on  a  profound  dis- 
turbance of  nutrition  that  it  can  fairly  be  said  to  result  from  any  disease 
which  from  its  debilitating  nature  may  interfere  with  the  nutrition  of  the 
bones.  In  this  way  individuals  whose  nutrition  has  been  seriously  af- 
cted  by  hereditary  syphilitis  may  develop  rhachitis. 

In  regard  to  the  actual  lesions  of  the  bones  present  in  syphilis  and 
rhachitis,  there  seems  to  be  a  concurrence  of  opinion  that  the  pathologi- 
cal conditions  are  quite  different.  Thus,  syphilitic  bones  very  rarely 
present  the  spongy  tissue  peculiar  to  rhachitis,  and  rhachitic  bones  never 
show  the  osteophytes  of  syphilis. 

Prognosis. — The  prognosis  in  any  case  of  hereditary  syphilis  is  a  se- 
rious one.  In  addition  to  the  results  which  we  are  likely  to  have  from 
the  syphilis  of  the  parents  being  early  or  late  in  regard  to  the  impregna- 
tion, and  from  their  having  been  thoroughly  treated  or  not,  there  are 
certain  facts  to  be  remembered  concerning  the  infant  itself. 

The  prognosis  is  grave  inversely  to  the  number  of  weeks  after  birth 
when  the  disease  first  shows  itself.  The  milder  forms  of  the  eftlorescence 
justify  us  in  giving  a  better  prognosis  than  the  more  severe  ones.     In 


SPECIFIC   INFECTIOUS   DISEASES.  523 

addition  to  these  conditions  which  render  the  prognosis  more  favorable  are 
the  early  recognition  of  the  disease  and  the  institution  of  antisyphilitic  treat- 
ment, and  the  possibility  of  the  infant  being  fed  with  good  breast-milk  or 
with  a  carefully  prepared  substitute  food,  and  good  hygienic  surroundings. 

The  cases  in  which  the  spleen  is  much  enlarged  are  e\ddently  so  pro- 
foundly affected  by  the  secondary  anaemia  by  which  the  enlargement  is 
caused  that  the  prognosis  is  almost  invariably  bad,  and  the  degree  of 
splenic  enlargement  may  almost  be  taken  as  an  mdex  of  the  severity  of 
the  disease. 

The  opinion  which  we  give  to  the  parents  should,  however,  always 
be  very  guarded,  as,  even  though  the  disease  may  for  the  time  apparently 
be  entirely  cured,  it  is  always  liable  to  appear  again  in  later  childhood 
and  at  puberty.  When  the  disease  is  amenable  to  treatment  these  sec- 
ondary symptoms  almost  always  disappear  by  the  second  year,  and  in 
quite  a  large  number  of  cases,  where  proper  treatment  has  been  thor- 
oughly carried  out,  the  infant  recovers  entirely  and  is  as  well  and  strong 
as  though  it  had  never  had  syphilis.  In  another  set  of  cases,  however, 
although  the  disease  is  apparently  eradicated,  in  later  years  it  is  found  to 
have  left  its  marks  in  disturbances  of  the  different  functions  and  in  the 
general  lack  of  vigor  of  the  various  tissues. 

Treatment. — The  treatment  of  hereditary  syphilis  is  first  to  adapt  at 
once  as  nourishing  a  food  as  is  possible  to  the  infant's  digestion.  A  healthy 
mother  with  plenty  of  good  breast-milk  will,  as  a  rule,  provide  the  best 
food  for  her  infant. 

If  the  mother's  nutrition  is  reduced  by  syphilis  or  by  any  other  chronic 
disease,  the  infant  should  be  fed  on  a  properly  adjusted  substitute  food, 
wliile  the  general  hygiene,  such  as  fresh  ah',  sunlight,  and  warmth,  should 
be  carefully  regulated.  A  wet-nurse  should  not  be  employed  unless  she 
has  herself  had  syphilis,  in  which  case  the  same  rules  will  apply  to  her 
nursmg  as  to  that  of  the  syphilitic  mother. 

It  should  be  remembered  that  the  secretions  from  a  syphilitic  infant's 
mouth  are  very  infectious,  whether  the  disease  is  of  the  hereditary  or 
of  the  acquired  form.  If,  therefore,  the  mother  is  not  s}T3hilitic  and  the 
infant  has  acquired  m  any  way  a  syphilitic  lesion,  the  nursing  must  be 
discontinued  and  the  infant  fed  on  a  substitute  food. 

The  only  drug  which  can  be  depended  upon  in  the  treatment  of  the 
early  lesions  of  hereditar)^  syphilis  is  mercury.  This  drug  naturally  would 
be  employed  from  our  experience  with  it  in  acquired  syphilis,  where 
it  is  more  valuable  in  the  early  stage  of  the  disease  than  at  any  other 
period.  In  like  manner  iodide  of  potash  is  of  little  use  in  the  early 
stages  of  hereditary  syphilis,  while  it  becomes  useful  in  the  retarded  form, 
which  corresponds  to  the  later  stage  of  acquired  syphilis. 

It  is  important  carefully  to  adapt  the  form,  of  mercury  wliich  is  given 
to  the  syphilitic  infant  according  to  its  special  idiosyncrasy  for  the  drug, 
and  also  to  regulate  the  means  of  its  administration  according  to  the  ne- 


524  PKDT  ATI  IK'S. 

cossity  of  having  it  act  quickly,  as  is  indicated  in  tlie  more  severe  Ibrms 
of  the  disease,  and  according  to  the  sensitiveness  of  the  individual's  stomach 
or  skin.  Thus,  mercury  may  be  administered  either  through  the  mouth 
or  through  the  skin.  In  the  latter  case  it  may  be  applied  directly  in  the 
form  of  licfuid  or  ointment  or  by  means  of  subcutaneous  injections.  The 
last  method  should  be  used  in  very  urgent  cases  only,  for  the  tissues  and 
skin  of  the  syphilitic  infant  are  especially  liable  to  be  irritated  to  such  an 
extent  that  sloughing  may  take  place,  and  the  tissues  under  these  circum- 
stances are  readily  destroyed.  When  used,  it  should  be  in  the  form  ot 
corrosive  sublimate. 

The  corrosive  sublimate  should  never  be  given  subcutaneously  in 
larger  doses  than  0.0006  gramme  (j^^  grain).  Where  the  mercury  is  to 
be  applied  directly  to  the  skin  it  may  be  in  the  form  of  corrosive  subli- 
mate baths,  0.3  to  0.6  gramme  (5  to  10  grains)  to  each  bath  once  daily, 
but  practically  it  is  found  better  to  introduce  it  into  the  system  by  means 
of  an  ointment.  This  ointment  may  be  the  official  mercurial  ointment, 
either  in  full  strength  or  diluted  with  some  simple  ointment,  and  this 
may  be  applied  by  means  of  inunction,  as  is  the  custom  in  the  accjuired 
syphilis  of  adults.  After  the  infant's  skin  has  been  thoroughly  washed,  a 
small  portion  of  the  ointment  should  be  applied  to  its  back  and  rubbed 
carefully  and  gently  into  the  skin  for  ten  minutes.  On  the  next  day  the 
same  procedure  can  be  carried  out  on  the  front  of  the  chest ;  on  the  third 
day  in  the  axillary  regions ;  and  on  the  following  days  respectively  on  the 
outer  surfaces  of  the  arms  and  thighs.  We  have  found  that  the  most 
practical  way  of  applying  inunctions  to  these  infants  is,  after  having 
thoroughly  washed  the  abdomen,  to  spread  the  ointment  thickly  on  a 
piece  of  thin  soft  flannel  cut  so  as  to  reach  from  the  ensiform  cartilage  to 
the  pubes  and  to  extend  around  the  entire  abdomen.     This  ointment  is 

made  in  the  following  way  : 

Prkscriptiox  40. 
Metric.  Apothecary. 

Gramma. 
H    Unguenti  oleati  hydrurgyri,  I  H    Unguenti  oleati  hydrsirgyri, 

^      Unguenti  lanolini fiA  60|00  Unguenti  l;in( ilini aa  g  ii. 

M.  31. 

The  band  should  be  allowed  to  remain  in  place  for  forty-eight  hours. 
It  should  then  be  removed,  and,  after  the  skin  has  been  thoroughly  washed 
with  warm  water  and  soap  and  dried  with  a  soft  towel,  the  flannel  should 
again  be  spread  with  the  ointment  and  reapplied. 

In  giving  mercury  by  the  mouth  we  are  in  the  habit  of  using  the  official 
hydrargyrum  cum  creta.  We  usually  begin  with  0.06  gramme  (1  grain)  of 
the  drug,  administered  three  times  in  the  twenty-four  hours.  Within  a 
few  days  the  dose  is  increased  to  four  times  in  the  twenty-four  hours, 
and  if  no  unfavorable  symptoms  appear  it  is  again  raised  to  0.12  gramme 
(2  grains)  three  to  four  times  in  the  twenty-four  hours. 

The  unfavorable  symptoms  which  have  just  been  referred  to  as  pos- 


SPECIFIC    IXFECTIOUS    DISEASES.  525 

sibly  being  caused  by  the  drug  are  represented  by  diarrhoea.  We  must 
remember  that  the  infants  whom  we  are  treating  for  hereditary  syphilis 
are  so  young  that  the  sahvary  secretion  has  been  very  slightly  developed, 
and  that  therefore  we  naturally  do  not  salivate  an  infant  of  this  age  so 
readily  as  we  would  a  child  or  an  adult.  We  must  not,  however,  think 
that  we  can  be  guided  as  to  the  amount  of  mercury  we  are  introducing 
into  the  infant's  stomach  by  salivation,  which  is  usually  relied  upon  to 
indicate  the  physiological  action  of  mercury.  We  have  found  it  a  safe  rule 
to  continue  with  the  mercury  until  diarrhd'a  is  caused,  when  the  drug 
can  be  reduced  in  cjuantity,  or  even  be  omitted  for  a  few  days.  When 
the  intestine  has  become  less  sensitive  we  can  again  begin  with  a  smaller 
dose,  and  one  which  by  experiment  has  been  shown  not  to  cause  diar- 
rhoea in  the  especial  infant. 

Other  forms  of  mercury,  such  as  calomel  in  doses  of  0.006  gramme 
(yV  grain)  three  to  four  times  daily,  may  be  given  by  the  mouth  in  these 
cases. 

These  various  forms  of  juercury  should  be  tried  when  for  any  reason 
one  of  them  is  found  not  to  suit  the  case. 

For  the  treatment  of  the  fissures  which  occur  around  the  lips  and  the 
lesions  of  the  mouth,  as  well  as  those  which  occur  at  the  anal  orifice,  we 
are  in  the  liabit  of  using  a  simple  powder  of  calomel,  which  is  dusted  on 
the  part  affected.  The  mouth  should  be  carefully  cleansed  several  times 
during  the  day  and  a  Avash  of  chlorate  of  potash  used  at  least  twice  a  day. 
In  seme  cases,  although  rarely,  nitrate  of  silver  is  needed  as  an  application 
to  the  ulcers  when  they  are  intractable.  When  there  are  crusts  around 
the  lips  and  in  the  neighborhood  of  the  fissures,  or  where  anal  condylo- 
mata are  present,  the  mercurial  ointment  just  spoken  of  is  of  much 
benefit.  The  crusts  should  be  carefully  removed  from  the  nose  and  this 
same  ointment  gently  applied  to  the  lesions.  The  application  of  this  oint- 
ment to  the  abdomen  is  at  times  followed  by  an  eczematous  irritation  of 
the  skin  of  the  abdomen.  Under  these  circumstances  any  simple  emol- 
lient should  be  applied  in  place  of  the  mercurial  for  a  few  days  until  the 
skin  has  recovered,  and  the  mercury  can  then  be  further  diluted  with 
lanoline  or  some  simple  ointment  and  reapplied,  thus  finally  adjusting  tlie 
strength  of  the  mercurial  to  the  vulnerability  of  the  infant's  skin. 

In  addition  to  the  mercurial  treatment,  tonics  in  some  form,  especially 
iron,  are  at  times  required.  It  is  usually  in  the  later  stages  of  the  disease 
that  they  are  indicated,  and  in  cases  in  which  the  persistence  of  the 
splenic  enlargement  shows  the  presence  of  profound  secondary  anemia. 

After  all  the  symptoms  of  syphilis  have  disappeared  and  the  infant  is 
entirely  well,  the  mercurial  treatment  should  be  continued  for  some 
months,  and  also  later  during  the  first  three  or  four  years  of  its  life,  at 
intervals  of  three  or  four  months,  even  when  there  is  no  return  of  the 
syphilitic  symptoms.  It  should  likewise  be  given  at  intervals  during 
the  period  of  the  second  dentition,  and  again  at  puberty.     This  treat- 


526  PEDIATRICS. 

ment  is  especially  important  whether  the  infant  appears  to  be  in  good 
health  or  not,  as  it  tends  to  prevent  a  recurrence  of  the  disease,  and 
we  should  remember  that  a  recurrence  often  proves  very  intractable  to 
treatment. 

The  following  cases  illustrate  the  different  phases  of  hereditary  syphilis 
and  the  different  conditions  which  are  liable  to  be  met  with  in  this  disease : 

The  first  infant  was  three  weeks  old.  Its  mother  looked  well  and  strong,  denied 
having  had  any  miscarriages  or  disease  of  any  kind,  and  asserted  that  the  father  was 
also  healthy.  Both  of  these  statements  were  probably  untrue,  but  an  excellent  oppor- 
tunity for  making  a  diagnosis  simply  by  inspection  and  by  a  physical  examination  was 
given. 

At  birth  the  infant  was  puny  and  atrophic.  It  soon  began  to  have  occlusion  of  the 
nares.  When  one  week  old,  an  efflorescence  of  papules  appeared  on  its  arms,  legs,  and 
feet,  with  pustules  on  the  palms  of  the  hands  and  the  soles  of  the  feet.  It  did  not 
vomit.  The  fascal  movements  were  of  a  good  color  and  fairly  well  digested.  The  heart 
and  lungs  were  normal.  The  splenic  area  of  dulness  was  slightly  increased,  but  the 
spleen  could  not  be  felt.  There  were  marked  fissures  at  the  angles  of  the  mouth,  a 
muco-purulent  discharge  from  the  nose,  and  crusts  forming  on  the  eyebrows.  The 
mouth  and  throat  showed  nothing  beyond  a  pronounced  erythema.  There  were  papules 
and  pustules  on  the  body,  and  a  squamous  as  well  as  a  pustular  efflorescence  on  the 
palms  of  the  hands  and  the  soles  of  the  feet.  There  were  maculie  on  the  buttocks. 
The  anus  showed  nothing  abnormal.  The  temperature  was  normal.  The  infant  looked 
fairly  well  nourished. 

There  could  be  no  question  about  the  diagnosis  in  a  case  like  this,  and  the  state- 
ments of  the  mother  regarding  herself  and  her  husband  were  entirely  ignored,  for  by 
simple  inspection  it  was  clear  that  it  was  a  case  of  hereditary  syphilis. 

The  next  infant  was  six  months  old.  The  mother,  a  healthy-looking  woman  with 
plenty  of  breast-milk,  nursed  the  infant.  She  had  had  one  miscarriage,  in  the  third 
month,  and  this  was  her  first  child.     The  father  denied  having  had  any  venereal  disease.  ■ 

At  birth  the  infant  was  rather  atrophied  and  had  a  general  papular  efflorescence 
all  over  it,  and  later  a  squamous  efflorescence  on  the  palms  of  the  hands  and  the  soles 
of  the  feet.  It  always  had  marked  occlusion  of  the  nares  (snuffles).  The  infant  Avas 
immediately  placed  under  treatment,  and  at  six  months  looked  well  nourished.  It  was 
a  case  of  hereditary  syphilis,  and  showed  the  beneficial  results  of  good  breast-milk  and 
mercury,  for  it  was  very  large  for  its  age  and  was  fat  and  strong-looking.  It  had, 
/^  however,  certain  lesions  of  the  bones  which  were  the  result  of  the  syphilitic  manifes- 
tations which  it  presented  at  birth.  One  of  these  lesions  was  represented  in  the 
marked  prominences  on  either  side  of  the  frontal  bone,  with  a  somewhat  depressed 
sulcus  between  them. 

The  first  phalanx  of  the  left  little  finger  and  that  of  the  left  third  finger  were 
swollen  and  somewhat  reddened,  and. the  tissues  had  a  tendency  to  break  down.  This 
is  the  condition  which  has  already  been  described  as  syphilitic  dactylitis.  Cases  of 
tuberculosis  of  the  bone  often  simulate  this  condition,  and,  in  fact,  so  nearly  approach 
it  in  appearance  that  the  two  diseases  cannot  be  distinguished  by  simple  inspection. 
The  diagnosis  must  be  made  by  considering  the  other  symptoms. 

The  syphilitic  infant  is  described  essentially  as  atrophic  ;  this  is,  as  a  rule,  the  case 
only  when  it  is  deprived  of  good  breast-milk  or  of  a  properly  proportioned  substitute 
food,  the  atrophy  being  usually  a  fault  in  diet,  provided  that  the  intra-uterine  nutrition 
has  been  good. 

Syphilis  is  so  prolific  a  source  of  miscarriage  that  a  history  of  miscar- 
riage in  the  mother  justifies  us  in  looking  with  suspicion  on  a  doubtful 


SPECIFIC   INFECTIOUS  DISEASES.  527 

lesion  of  the  skin  in  her  infant.  A  woman  may  have  a  number  of  mis- 
carriages caused  by  syphilis,  and  may  then,  if  she  has  been  treated  with 
mercury,  give  birth  to  a  living  syphilitic  infant,  or  to  one  that  is  healthy. 
These  facts  are  important  for  us  to  remember  when  we  are  considering 
the  prognosis  in  a  case  of  hereditary  syphilis. 

The  next  infant  illustrates  one  of  the  many  unusual  forms  of  syphilis 
which  may  manifest  itself  in  infancy. 

A  male,  four  months  old,  was  brought  to  the  clinic  with  syphilis  of  a  rather  aggra- 
vated type,  and  among  other  lesions  with  condylomata  at  the  anal  orifice. 

It  had  a  general  papular  efflorescence  on  the  face,  body,  and  limbs,  including  the 
palms  of  the  hands  and  the  soles  of  the  feet.  The  left  arm  hung  helpless  by  its  side. 
The  left  leg  was  also  somewhat  affected.  On  examining  the  arm  there  was  found  a 
small,  hard,  painful,  circumscribed  swelling  at  the  lower  end  of  the  humerus.  No  crep- 
itation was  detected. 

The  condition  was  one  of  the  osseous  lesions  of  syphilis,  an  osteochondritis  ac- 
companied by  periostitis,  which  caused  so  much  pain  on  movement  as  to  disable  the 
limbs  and  simulate  both  paralysis  and  fracture.  Mercury  was  given  and  the  infant 
recovered. 

The  next  case  is  of  remarkable  interest,  owing  to  the  form  and  appearance  of  the 
efflorescence,  which,  although  unusual,  is  so  characteristic  that  it  could  represent  no 
other  disease  than  syphilis. 

The  infant  was  six  weeks  old.  The  mother  stated  that  she  had  been  married 
about  three  years,  had  had  two  children,  and  had  had  no  miscarriages.  She  said  that 
the  father  was  well  and  strong,  and  that  neither  of  them  had  had  any  efflorescence 
on  their  skin.  The  older  infant  was  fourteen  months  old,  and  was  healthy.  The 
younger  infant  was  being  nursed  by  its  mother.  At  birth  it  was  apparently  healthy 
and  well  nourished.  Its  skin  was  clear,  its  body  fat,  and  there  was  no  occlusion  of 
the  nares.  This  condition  continued  until  it  was  eight  days  old.  It  then  began  to 
have  occlusion  of  the  nares  (snuffles),  a  slightly  hoarse  voice,  and  an  efflorescence  on 
various  parts  of  the  body  and  limbs.  This  efflorescence  consisted  mostly  of  maculae, 
many  of  which  were  circumscribed  by  healthy  skin.  They  varied  in  size  from  0.6  to 
1.25  cm.  {\  to  \  inch). 

Plate  XI. ,  facing  page  606,  shows  a  number  of  lesions  represented  in  this  case. 

In  addition  to  the  maculae,  which  varied  from  a  delicate  pink  to  a  yellowish-white 
color,  there  was  a  pustule  on  the  outer  side  of  the  leg  just  below  the  knee.  On  the 
inner  edge  and  almost  on  the  back  of  the  foot  were  the  remains  of  a  bleb  which  had 
broken  down  and  had  been  emptied  of  its  contents.  '  There  was  also  on  the  inner  side 
of  the  foot,  nearer  to  the  heel,  a  small  ulcer.  The  entire  skin  of  the  heel  was  reddened 
and  had  a  shining  appearance.  The  erythematous  lesions  in  places  on  the  leg  were 
surrounded  by  normal  skin,  presenting  a  mottled  appearance,  and  there  were  white 
spots  on  the  skin.  These  latter,  however,  were  caused  merely  by  the  peculiar  distri- 
bution of  the  syphilitic  maculae. 

In  addition  to  these  lesions  on  the  leg  there  were  a  few  ulcers  on  the  buttocks, 
and  in  addition  to  the  maculae  on  the  soles  of  the  feet  there  were  some  on  the  palms 
of  the  hands.  A  few  scales  showing  a  squamous  condition  could  be  seen  on  the  left 
leg,  but  this  lesion  was  not  a  prominent  one. 

The  eyes  were  not  affected.  There  were  a  few  fissures  about  the  mouth,  but  no 
lesions  of  the  buccal  mucous  membrane,  and  there  were  no  gummata  around  the  anus. 

The  treatment  of  this  case  was  by  inunction  with  the  oleate  of  mercury  ointment 
and  by  the  administration  of  hydrargyrum  cum  creta. 

Fig.  119  represents  the  lesions  of  syphilis  on  the  soles  of  the  feet  in  a  male.  The 
lesions  consisted  of  a  number  of  bullae,   some  of  which  had  burst,  and  the  tissue 


528 


PEDIATRICS. 


beneath  having  broken  down,  ulcerations  were  formed.     There  were  also  a  few  papules, 
some  smaller  bullte,  and  some  pigmented  areas. 

This   same    case  had  the   "waxen"  pallor  of  the  skin,   so   characteristic  of  the 
higher  grades  of  grave  anaemias.     There  was  moderate  enlargement  of  the  liver,  which 


Fig.  119. 


7^Si5W^~ 


1 


^Siwa^ 


Syphilitic  maoulaj,  ulcers,  and  hulla?  on  the  soles  of  the  feet.    Male,  2%  months  old. 

on  palpation  was  found  to  be  hard  and  somewhat  tender.  The  inguinal  glands  were 
slightly  enlarged.  The  post-aural  glands  were  enlarged.  The  spleen  was  much 
enlarged  and  extended,  as  indicated  in  Fig  120  by  the  black  line,  from  the  fifth  rib 
to  the  left  inguinal  region.  It  was  hard,  but  was  not  tender.  There  were  no  other 
glandular  enlargements.     The  examination  of  the  blood  was  as  follows  : 

Nov.  17.  Nov.  20. 

Erythrocytes 3,387,000  3,300,000 

Hfemo^lobin 47  per  cent.  45  per  cent. 

Leucocytes 20,000  20,000 

There  was  a  considerable  variation  in  the  size  of  the  erythrocytes,  which  were  pale 
in  color.  There  was  poikilocytosis  in  a  moderate  degree  ;  there  were  also  some  micro- 
cytes  and  megalocytes.  The  mononuclear  elements  predominated  (about  three-quar- 
ters).    The  eosinophiles  were  not  numerous. 

Fig.  120. 


Mftle,  2%  months  old.    Congenital  syjihilis.    Grave  secondary  an;rmia.    Lower  horderof  ribs,  iiftli  rib, 
and  enlarged  spleen  marked  in  black. 


PLATE   YII. 


Hereditary  syphilis  in  a  hoy  R  years  oM.    A.  B.  C,  D,  E,  represent  thintenin?  of  periosteal  boneof  the 
tibise  and  fibuire  in  the  order  of  the  different  stages  of  development. 


SPECIFIC    I^TECTIOUS    DISEASES.  599 

Late  Manifestations  of  Hereditary  Syphilis. — Symptoms  axd  Patho- 
logical Anatomy. — The  manifestations  of  hereditary  syphihs  which  appear 
at  birth  usually  develop  in  the  first  three  or  four  months  of  the  Infant's  life. 
In  certain  cases  of  syphilis  which  are  without  doubt  of  the  hereditary  form, 
either  no  symptoms  whatever  are  noticed  in  the  early  years  of  hfe,  or  they 
are  so  slight,  or  so  lacking  in  the  characteristics  of  syphilis,  that  it  is  some- 
times impossible  to  recognize  them  as  syphilitic  lesions.  The  lesions  of  this 
late  hereditary  form  correspond  to  the  tertiary  lesions  of  the  acquired  form. 
They  appear  in  different  periods  of  childhood  or  at  puberty.  These  periods 
correspond  to  the  time  when  a  fresh  outbreak  of  an  attack  of  syphilis 
which  has  occurred  in  the  early  months  of  life  is  apt  to  take  place.  This 
is  significant  as  leading  us  to  suspect  that  the  early  symptoms  of  the 
disease  have  been  overlooked  rather  than  to  believe  that  they  did  not 
occur. 

Bones. — The  lesions  of  the  bones  hold  a  prominent  place  hi  these  later 
manifestations  of  hereditarj^  syphilis.  These  lesions  may  be  in  the  form 
of  a  periostitis,  or  an  actual  necrosis  of  the  bone  may  take  place  either  in 
connection  with  a  dactylitis  or  Avith  a  simple  lesion  of  the  osseous  tissue 
in  any  of  the  bones. 

As  these  later  forms  of  hereditary  sypMlis  merely  represent  the  same 
conditions  which  are  met  A^dth  m  tertiarj^  acquired  syphilis,  we  should  expect 
the  most  varied  lesions.  In  this  late  form  of  hereditary  syphilis  the  bones 
of  the  nose  are  frequently  involved,  and  a  flattening  of  the  bridge  of  the 
nose  is  not  uncommon.  The  cranial  bones  show  certain  alterations  which 
at  times  are  quite  characteristic.  The  frontal  bone  may  present  a  promi- 
nence on  either  side,  which,  with  a  depression  more  or  less  deep  between  the 
prominences,  causes  such  a  peculiar  conformation  of  the  head  as  to  be  almost 
characteristic  of  syphilis.  In  addition  to  these  frontal  prominences,  at  times 
there  is  a  prominence  of  the  centre  of  the  frontal  bone,  which,  with  the  ap- 
parent flattening  on  either  side,  causes  a  peculiar  shape  simulating  the  kee} 
of  a  ship.  Sometimes  protuberances  similar  to  those  which  have  been  de- 
scribed of  the  frontal  bone  may  appear  on  the  parietal  bones.  When  they 
are  bilateral  the  sagittal  suture  appears  as  a  depressed  sulcus  between 
them,  and  this  deformity  of  the  skull,  from  its  resemblance  to  the  shape 
of  the  nates,  has  been  designated  by  Parrot  as  the  natiform  skull. 

These  tuberosities  on  the  skull  may  also  appear  upon  the  long  bones, 
either  in  the  diaphysis  or  in  the  epiphysis.  When  the  tibia  is  affected 
there  is  often  so  marked  an  increase  in  parts  of  the  shaft  of  the  bone, 
especially  its  middle  third,  that,  as  the  enlargement  is  chiefly  in  the  ante- 
rior portion,  the  swelling  when  prominent  gives  an  appearance  of  curva- 
ture to  the  bone.  This  is,  however,  only  a  seeming  curvature,  as  the 
posterior  portion  of  the  bone  is  not  affected. 

Mental   Development. — An  interference   with  the  growth   of   children 

who  are  affected  by  these  various  osseous  lesions  of  svphilis  is  not  un- 

34 


530 


PEDIATRICS. 


common.  There  is  frequently  a  lack  of  development,  which  shows  itself 
usually  in  a  failure  of  the  individual  to  attain  the  ordinary  height.  The 
mental  development  is  retarded,  the  children  often  appearing  to  he  a 
number  of  years  younger  than  they  really  are.  This  condition  Fournier 
has  designated  as  infantilism. 

Teeth. — The  first  set  of  teeth  in  infants  with  hereditary  syphilis  may 
show  the  same  markings  which  are  characteristic  of  the  second  dentition, 
but  usually  have  nothing  characteristic  about  them  ;  they  show  a  lack  of 
nutrition,  a  condition  which  may  arise  from  many  other  morbid  pro- 
cesses. 

The  second  set  of  teeth,  however,  present  certain  characteristics. 
These  characteristics  are  shown  especially  in  the  two  middle  upper  in- 
cisors, in  which  the  cutting  edge  of  the  tooth  is  worn  away,  leaving  a  convex 
surface  with  the  convexity  upward.     The  teeth  are  also  apt  to  be  some- 

FiG.  122. 


Late  manifestations  of  congenital  syphilis,  showing  the  typical  notched  and  pegged  teeth  of  the 

second  dentition. 


Avhat  far  apart,  and,  as  the  child  grows  older,  to  assume  a  peg  shape. 
_The  especial  characteristics  of  syphilitic  teeth  were  first  described  by 
Hutchinson.  This  peculiar  shape  of  the  teeth  is  not  ahvays  present  in 
syphilis,  but  when  it  appears  it  is  certainly  very  suggestive  of  the  disease. 
As  was  pointed  out  by  Coleman,  the  dentist  who  examined  Hutchinson's 
cases,  in  nearly  every  one  of  them  there  was  a  deficiency  in  the  superior 
alveolar  arch  at  the  anterior  portion,  so  great  in  some  cases  that  when 
the  jaws  were  closed  the  upper  and  the  lower  incisors  did  not  come 
together. 

Fournier  has  called  attention  to  the  frecjuent  involvement  of  the 
molars.  The  four  cusps  may  be  replaced  by  yellowish  pegs  which  are 
free  from  enamel.  These  may  soon  wear  down  to  the  surface  of  the  body 
of  the  tooth,  presenting  a  smooth  crown  with  yellow  centre  and  narrow 
band  of  white.  Absence  of  canines  and  wide  separation  of  the  incisors 
are  often  caused  by  congenital  syphilis. 


SPECIFIC    INFECTIOUS  DISEASES. 


531 


Figs.  121  and  122  represent  syphilitic  teeth  of  the  second  dentition. 
They  are  all  more  or  less  disorganized  in  a  way  which  might  occur  from 
any  cause  which  Avould  interfere  with  the  normal  development  of  the 
teeth  and  cause  their  early  decay. 

Nails. — The  onychia  which  occurs  as  one  of  the  earlier  manifestations 
of  hereditary  syphilis  has  been  described  on  page  518.  In  the  late  form 
of  syphilis  another  form  of  onychia  is  met  with,  characterized,  according 

Fig.  123. 


The  late  manifestations  of  congenital  syphilis  in  a  boy  6  years  old,  thow  hig  periostitis  of  both  radii  and 
both  tibiae  with  an  area  of  softening  in  the  lower  third  of  the  right  tibia. 


to  Post,  by  a  swelling  at  the  base  or  the  side  of  the  nail,  which  becomes 
thickened,  fissured,  and  brittle,  with  more  or  less  deformity  of  the 
phalanx. 

Eye. — In  the  late  form  of  syphilis  a  peculiar  inflammation  of  the 
cornea  at  times  appears.  It  usually  begins  Avith  a  cloudiness  of  the  sub- 
stance of  the  cornea,  with  ciliary  congestion.  The  entire  cornea  in  this 
way  becomes  clouded.  The  affection  is  not  accompanied  usually  by  pain, 
and  does  not  show  any  special  congestion  of  the  conjunctivae.  Hutchin- 
son says  that  it  is  always  symmetrical,  although  at  first  it  is  apt  to  begin 
with  one  eye  and  later  to  attack  the  other.     The  interval  betv/een  the 


532  PEDIATRICS. 

two  attacks  may  extend  over  several  years.  This  disease  is  called  inter- 
stitial keratitis,  and  may  for  a  few  weeks  seriously  interfere  with  the  sight. 
It  usually  disappears  under  treatment  without  leaving  any  trace  of  the 
disease  behind  it.  On  the  other  hand,  opacities  are  sometimes  left  which 
interfere  with  vision.  The  total  duration  of  the  disease  varies  from  six 
to  eighteen  months.  Interstitial  keratitis,  according  to  Post,  occurs  most 
frec{uently  in  female  subjects,  and  is  most  common  between  the  ages  of 
ten  and  fifteen,  although  it  may  occur  much  earlier,  and,  according  to 
Fournier,  may  even  be  met  with  at  birth.  Complications  may  arise  in 
the  shape  of  iritis,  choroiditis,  and  retinitis. 

Far. — Disturbances  of  hearing  may  occur  from  a  number  of  causes, 
especially  from  those  secondary  to  diseases  of  the  pharynx.  An  especial 
form  of  deafness,  however,  without  any  special  lesions  to  explain  it,  occurs 
in  the  syphilis  of  childhood,  is  usually  intractable  to  treatment,  and  per- 
sists into  later  life.  Extensive  ulcerations  produced  by  syphilis  may  occur 
in  the  nose  and  jjharynx  at  any  time  during  childhood. 

Nervous  System. — Syphilis  of  the  nervous  system  may  be  congenital 
or  acquired,  involving  either  the  brain  or  cord.  It  is  very  rare  in  children. 
It  may  occur  as  a  diffuse  inflammation  of  the  meninges,  as  localized 
gummata,  or  as  an  endarteritis.  Syphilitic  meningitis  and  endarteritis 
present  essentially  the  same  symptoms  as  in  adults.  The  brain  may  be 
atrophied,  showing  flattening  of  the  convolutions  and  distension  of  the 
ventricles  with  fluid.  Gummata  of  the  brain  or  cord  present  no  symp- 
toms in  themselves  to  distinguish  them  from  other  cerebral  tumors  (see 
page  1001).  The  lesions  in  the  cord  are,  however,  apt  to  be  widely 
distributed,  involving  the  cervical,  dorsal,  and  lumbar  regions,  with  preser- 
vation of  some  of  the  functions  and  complete  loss  of  others.  The  rapid 
diminution  of  some  symptoms  and  the  persistence  of  others  are  character- 
istic. The  presence  of  syphilis  elsewhere  and  the  marked  improvement 
under  antisyphilitic  treatment  are  important  points  in  the  diagnosis.  Syphi- 
litic endarteritis  and  multiple  gummata  of  the  base  have  been  observed  in 
j^nfants  as  early  as  fifteen  months. 

Treatment. — The  treatment- of  the  lesions  which  usually  occur  in  the 
retarded  form  of  syphilis  is  essentially  with  iodide  of  potash,  either  alone 
or  in  combination  with  some  mercurial.  The  iodide  of  potash  should  be 
given  at  first  in  doses  of  0.12  or  0.18  gramme  (2  or  3  grains),  and  this 
dose  should  be  gradually  increased  to  0.36  or  0.6  gramme  (6  orlOgrains), 
or  even  more,  as  children  often  tolerate  this  drug  remarkably  well,  and 
large  doses  are  usually  indicated. 

When  iodide  of  potash  is  given  in  combination  with  mercury,  it  is 
well  to  begin  with  corrosive  sublimate  in  doses  of  0.0006  grarimie  (y^o 
grain)  and  gradually  to  increase  the  dose.  Corrosive  sublimate  is,  how- 
ever, so  apt  to  cause  disturbance  of  digestion  that  we  prefer  to  treat  these 
cases  by  giving  the  iodide  of  potash  uncombined  with  any  other  drug,  by 
the  mouth,  and  by  applying  the  mercurial  ointment  to  the  skin. 


SPECIFIC   IXFECTIOUS   DISEASES.  533 

The  treatment  of  these  later  manifestations  of  syphilis  must  often  be 
continued  for  long  periods.  It  should  be  combined  with  general  symp- 
tomatic treatment,  especially  Avith  reference  to  the  anaemia,  malnutrition, 
and  indigestion  which  are  usually  present.  Good  food  and  a  healthful  out- 
of-door  life  should  be  provided  as  liberally  as  possible. 

The  following  case  illustrates  the  retarded  form  of  sypliilis,  and  shows 
the  importance  of  carefully  reviewing  the  previous  history  not  only  of  the 
child,  but  also  of  its  parents  : 

The  child  was  a  girl,  thirteen  years  of  age.  The  mother  had  no  other  children 
nor  any  miscarriages.  She  had  always  been  well,  and  had  never  shown  any  manifesta- 
tions of  syphilis. 

The  father,  so  far  as  could  be  ascertained,  until  recently  had  always  been  well  and 
strong,  and  had  shown  no  signs  of  syphilis.  About  one  year  previous  he  began  to  have 
cerebral  symptoms,  which  rapidly  increased,  were  accompanied  by  paralysis,  and  were 
undoubtedly  of  syphilitic  origin. 

We  were  first  called  to  see  this  child  when  she  was  suffering  from  a  mild  attack  of 
appendicitis,  which  did  not  come  to  operation.  At  that  time  we  noticed  a  peculiar  con- 
formation of  the  upper  incisors,  which  made  us  at  once  suspect  a  case  of  hereditary 
syphilis.  On  further  inquiry  we  learned  that  she  had  been  treated  some  years  earlier 
by  an  oculist  for  keratitis.  The  upper  incisors  Avere  abnormally  far  apart  and  stunted 
in  their  growth.  They  were  notched,  as  was  also  the  left  lateral  incisor,  which  was 
peg-shaped  and  by  its  clearly  cut  notch  represented  more  nearly  than  the. others  the 
characteristic  syphilitic  teeth.  The  right  upper  lateral  incisor  had  a  peculiar  shape,  the 
crown  of  the  tooth  coming  down  almost  to  a  point.  The  other  teeth  were  in  many 
places  deprived  of  their  dentine,  and  were  in  various  stages  of  disorganization. 

On  recovering  from  the  appendicitis  the  child  remained  in  a  weak  condition  during 
the  following  year,  looked  sallow,  and  had  continual  headaches,  which  did  not  improve 
under  the  usual  remedies.  Treatment  with  iodide  of  potash  was  not  only  followed  by 
the  disappearance  of  the  headaches,  but  also  resulted  in  a  healthy  appearance  of  the 
child,  who  became  perfectly  well. 

The  foUowmg  case  is  an  illustration  of  the  various  tertiary  lesions  of 
syphilis : 

A  girl,  three  and  one-half  years  old,  had  certain  lesions  on  the  face,  arms,  hands, 
and  feet,  which  were  the  result  of  congenital  syphilis.  When  this  child  was  born  she 
was  apparently  healthy.  When  she  was  three  months  old  she  was  noticed  to  have 
occlusion  of  the  nares,  and  at  that  time  she  had  an  attack  of  bronchitis  lasting  for  three 
weeks.  It  was  said  that  no  efflorescence  was  ever  noticed  on  her  skin.  When  she  was 
seven  months  old  her  hands  began  to  swell,  and  at  fourteen  months  the  tissues  around 
the  metacarpal  bones  of  the  little  fingers  of  both  hands  became  reddened  and  ulcerated 
and  the  fingers  assumed  the  pyriform  shape  characteristic  of  syphilitic  dactylitis. 
When  the  child  was  about  sixteen  months  old  the  feet  began  to  svrell,  and  in 
certain  parts,  especially  the  metatarsal  bones  of  the  right  foot,  the  skin  became  red- 
dened. When  the  child  was  three  years  old  pieces  of  dead  bone  began  to  come  away 
from  the  hands,  and  this  continued  for  some  time.  At  the  same  age,  swellings  began 
to  appear  over  the  upper  maxillary  bones,  and  an  extensive  reddened  and  swollen 
condition  of  the  tissues  existed  under  the  right  eye.  The  fontanelles  w-ere  closed. 
There  were  evidently  a  periostitis  and  an  osteochondritis  of  the  right  arm,  and  there 
was  also  an  enlargement  of  the  left  ankle,  accompanied  by  ulceration  on  the  outer  side 
of  the  malleolus. 


534 


PEDIATHIC 


The  child  -was  treated  with  the  rnnihinHtion  ofnierciiry  find  indidf  of  pritash  shown 
in  the  followinir  prescription  • 

Fig.  124. 


yieiric 


Late  manifestations  of  syphili?.     Female,  Z'^4  years  old, 
PRE.SCRIPTI0X    -il. 

Gramma. 


Apothecary. 


R    Hydrarg.  chloridi  oorro.-ivi 0^03         R    Hydrarg.  ehloridi  corrosi%T gr.  ss  , 

Potassii  iodidi 3i75  Potassii  iodidi. ji; 

Aq.  destil 6000  Aq.  de,?til 5ii. 

S. — 2  c.c.  [h  drachm)  3  or  4  times  in  2-1  hours. 

"While  it  was  taking  this  medicine  all  its  symptoms  abated,  it  seemed  better  and 
brighter,  and  the  lesions  showed  a  tendency  to  heal.  Whenever  the  naedicine  was 
omitted  all  the  previous  symptoms  returned. 

The  tbllo\\ing  case  illustrates,  among  other  interesting  points,  this  saiiie 
lesion  of  the  bones. 

The  boy  was  six  years  old.  He  was  ratner  pale,  and  had  a  somewhat  peculiar 
frontal  development,  which  well  illustrates  one  form  of  syphilitic  head. 


SPECIFIC    INFECTIOUS    DISEASES.  535 

There  was  a  slight  depression  of  the  bridge  of  the  nose  and  the  bulging  of  the  fore- 
head on  either  side  just  above  the  orbital  ridges.  These  prominences  were  accentuated 
by  the  deep  sulcus  between  them,  extending  from  the  depressed  nasal  bones  upward 
almost  to  the  margin  of  the  hair.     This  condition  represents  the  typical  syphilitic  head. 

The  boy  was  in  fair  health,  and  had  nothing  abnormal  about  him  on  careful  physi- 
cal examination.  His  mother  brought  him  to  the  clinic  to  receive  a  course  of  treatment 
for  a  few  months  in  order  to  prevent  a  recurrence  of  his  infantile  syphilis. 

The  boy  had  been  treated  at  the  Children's  Hospital  w-hen  he  was  six  weeks  old. 
The  mother  had  been  well  and  strong,  and  had  never  had  any  other  children  nor  any 
miscarriages.  The  father  had  had  a. primary  syphilitic  lesion  one  year  previous  to  the 
birth  of  the  child,  which  was  followed  by  secondary  manifestations.  The  mother  had 
plenty  of  good  breast-milk,  and  nursed  her  infant  until  he  was  nineteen  months  old. 
He  was  never  atrophic,  and  although  pale  w-as  apparently  well  nourished.  At  birth 
he  showed  a  bullous  efflorescence  of  medium  grade.  During  the  early  weeks  of  his 
life  he  did  not  receive  any  medical  treatment,  although  he  had  a  general  efflorescence 
of  macules,  pustules,  and  bullae.  At  about  the  fifth  week  he  lost  the  use  of  his  left 
arm.  When  seen  at  the  sixth  week  he  showed  a  number  of  lesions  besides  those 
described,  and  it  was  doubtful  if  he  would  live.  These  lesions  consisted  of  fissures  at 
the  corners  of  the  mouth,  mucous  patches  in  the  mouth,  condylomata  of  the  anus,  and 
occluded  nares.  There  was  not  at  that  time  the  peculiarly  formed  bead  w^hich  is  now 
present.  The  left  arm  was  helpless  and  was  supposed  to  be  broken  ;  in  fact,  there  was 
some  crepitation,  and  probably  there  was  a  slight  separation  of  the  epiphysis  of  the 
distal  end  of  the  humerus.  There  seemed  to  be  considerable  pain  in  the  arm,  which 
made  the  infant  restless  and  fretful.  Insomnia  was  a  prominent  symptom.  The  arm 
was  put  in  a  light  splint,  and  the  oleate  of  mercury  ointment  (Prescription  40,  page 
524)  was  ordered. 

The  infant  was  not  seen  for  a  week.  When  he  w-as  brought  back  to  the  hospital 
the  right  arm  was  found  to  be  helpless,  and  the  mother  stated  that  the  ointment  had 
been  discontinued,  as  it  caused  excoriation  of  the  skin.  The  ointment  was  then  re- 
duced one-half  with  lanoline,  and  hydrargyrum  cum  creta  was  given  three  times  daily 
in  doses  of  0.06  gramme  (1  grain). 

In  three  days  he  was  much  better,  the  paralysis  soon  disappeared,  and  nothing 
abnormal  was  detected  about  the  arms.  The  hydrargyrum  cum  creta  was  increased 
to  0.24  gramme  (4  grains),  but  as  this  caused  diarrhoea  the  dose  in  a  few  days  had 
to  be  reduced  to  0.18  gramme  (3  grains).  In  the  course  of  the  next  month  the  nasal 
symptoms  and  the  efflorescence  had  disappeared,  and  the  infant  seemed  perfectly  well. 

Six  months  later  he  was  brought  back  to  the  hospital  wath  a  return  of  the  condylo- 
mata and  a  slight  papular  efflorescence.  The  same  treatment  as  before  was  carried  out. 
The  syphilitic  manifestations  disappeared,  and  did  not  return- 
He  was  kept  under  observation  and  treated  from  time  to  time  fcr  three  or  four 
years.     The  first  teeth  were  cut  at  nine  months,  and  w'ere  in  fair  condition. 

THE  EXANTHEMATA. 

In  contradistinction  to  the  various  diseases  of  the  skin  which  derma- 
tologists are  accustomed  to  designate  as  exanthems  of  local  origin  are 
certain  acute,  specific,  infectious  diseases  which  are  called  the  exanthe- 
mata. This  group  of  infectious  diseases  is  of  especial  interest  in  con- 
nection ^^"ith  children,  as  it  is  among  children  that  they  most  frequently 
occur.  They  can,  however,  attack  individuals  of  any  age.  Although 
none  of  these  diseases  are  entirely  self-protective,  yet  the  instances  in 
which  they  develop  in  an  individual  more  than  once  are  rare. 


536  PEDIATRICS. 

The  exanthemata  comprise  five  diseases, — scarlet  fever,  measles,  rubella, 
varicella  (chicken-jjo.v),  and  variola  (small-jyo.v).  Each  of  these  diseases  is 
characterized  by  certain  conditions  common  to  all.  Besides  being  infec- 
tious, each  disease  runs  a  definite  course  and  is  self-limited,  facts  which 
should  be  remembered  when  we  are  studying  its  diagnosis  and  treat- 
ment. 

The  course  of  tliese  exanthemata  from  the  time  when  the  infection 
takes  place  up  to  the  appearance  of  their  later  manifestations  may  be 
divided  into  distinct  stages.  In  the  first  of  these  certain  micro-organisms 
are  supposed  to  enter  the  system,  and,  so  far  as  external  appearances 
and  general  symptoms  are  concerned,  to  remain  dormant  for  a  time, 
constituting  what  is  called  the  stage  of  incubation.  This  stage  of  incuba- 
tion is  followed  by  certain  general  symptoms  resulting  from  the  supposed 
development  of  the  special  organisms  and  constituting  the  prodromal  stage. 
These  prodromal  symptoms  are,  after  intervals  varying  according  to  the 
special  disease,  followed  by  an  efflorescence  on  the  skm,  which  marks  the 
third  stage  of  the  disease,  called  the  stage  of  efflorescence.  The  efflores- 
cence in  its  turn  is  followed  by  what  is  called  the  stage  of  desquamation, 
this  desquamation  being  more  or  less  pronounced  in  proportion  to  the 
intensity  of  the  lesions  of  the  skin  which  have  occurred  during  the  stage 
of  efflorescence. 

Although  in  a  large  number  of  cases  the  diagnosis  of  these  diseases 
can  be  determined  by  the  appearance  of  the  efflorescence  and  its  location, 
yet  instances  occur  not  infrequently  in  which  the  efflorescence  is  very 
misleading.  We  should,  therefore,  be  familiar  with  tlie  characteristics  of 
the  other  stages,  for  it  is  by  carefully  considering  the  pictures  wliich  they 
present  to  us  as  a  whole  that  we  are  enabled  to  make  a  correct  differen- 
tial diagnosis  of  the  especial  case.  Thus,  a  papular  efflorescence,  although 
significant  in  most  cases  of  measles,  may  also  be  present  in  other  members 
of  the  group,  while  an  erythema  closely  resembling  scarlet  fever  may 
occur  in  variola,  measles,  or  rubella. 

SCARLET  FEVER. 

Scarlet  fever  is  an  acute  infectious  disease,  characterized  by  a  short 
incubation,  short  prodromal  stage,  erythematous  efflorescence,  pronounced 
desquamation,  and  long  course.  The  micro-organism  which  produces  it 
is,  according  to  Maliory,  one  of  the  protozoa,  but  he  does  not  claim  that 
a  definite  relation  between  this  organism  and  scarlet  fever  has  yet 
been  absolutely  shov\m.  With  the  exception  of  variola,  it  is  the  most 
dangerous  of  the  group,  and  is  therefore  the  most  important  of  all  the 
exanthemata. 

The  complications  of  scarlet  fever  are  so  much  more  serious  and  its 
sequelae  so  much  more  common  and  grave  than  those  of  varicella  and 
measles,  that  its  immediate  diagnosis  and  prompt  treatment  are  of  vital 


SPECIFIC   INFECTIOUS   DISEASES.  537 

necessity  in  every  community  where  numbers  of  children  are  liable  to  be 
attacked  by  the  disease. 

Etiology. — Scarlet  fever  is  the  most  irregular  of  all  the  exanthemata 
in  its  virulence  and  in  the  manifestations  w^hich  it  presents  in  different 
individuals.  It  is  usually  epidemic,  returning  to  the  same  localities  after 
a  period  of  years.  It  is  at  times  sporadic,  and  is  commonly  endemic  in 
large  cities.  The  epidemics  of  scarlet  fever  vary  in  severity,  so  that  we 
cannot  ascribe  the  virulence  of  the  disease  in  certain  years  to  individual 
susceptibility.  The  sporadic  cases  may  be  of  the  most  malignant  or  of 
the  mildest  type.  A  mild  case  may  give  rise  to  a  malignant  case  in 
another  child,  and  a  malignant  case  may  give  rise  to  a  mild  one.  The 
epidemics  of  scarlet  fever  spread  slowly,  in  contradistinction  to  those  of 
measles,  which  spread  rapidly.  Scarlet  fever  may  occur  more  than  once 
in  the  same  individual,  but  this  is  rare.  Instances  have  occurred  in 
which  a  child  has  had  scarlet  fever,  and,  on  returning  after  several  Weeks 
to  the  same  room,  even  after  it  had  been  disinfected,  has  again  con- 
tracted the  disease  in  its  typical  form.  The  bacterial  infection  is  sec- 
ondary, and  is  mostly  from  the  streptococcus  pyogenes.  The  skin  ap- 
pears to  be  the  chief  vehicle  of  transmission.  It  has,  however,  been 
shown  that  the  discharge  from  the  nose  and  throat,  both  in  the  early 
stages  of  the  disease  and  when  they  are  prolonged  even  after  the  stage 
of  desquamation,  may  be  a  source  of  infection.  The  contagium  has  a 
great  tenacity  for  clothing  and  other  articles,  and  may  be  capable  for 
many  months  of  reproducing  the  disease. 

In  reference  to  what  has  been  said  concerning  the  slow  spread  of 
scarlet  fever  during  epidemics  in  comparison  with  the  rapid  spread  of 
measles,  certain  clinical  facts  are  significant.  The  disease  does  not  seem 
to  be  very  infectious  in  its  early  stages.  We  are  thus  led  to  believe  that 
it  is  during  the  stage  of  desquamation  that  the  contagium  is  most  likely 
to  be  disseminated.  Measles,  on  the  other  hand,  is  known  to  be  highly 
infectious  in  its  early  stages,  and  for  this  reason  to  spread  more  quickly. 

Although  the  contagium  of  both  diseases  may  be  active  through  their 
whole  course,  yet  the  general  rule  is  early  infection  in  measles,  late  in 
scarlet  fever.     The  following  cases  illustrate  this  conclusion  : 

A  boy  six  years  old  and  a  girl  four  years  old  slept  in  the  same  room,  with  their 
beds  touching  each  other.  The  boy  was  taken  sick  May  1,  but  remained  in  the  same 
room  with  his  sister  during  that  day  and  the  following  night.  He  was  seen  by  us 
early  on  the  morning  of  May  3,  and  was  then  found  to  have  scarlet  fever.  His  sister 
was  taken  to  the  country,  and  the  boy  was  left  in  charge  of  a  trained  nurse.  There  was 
absolutely  no  communication  between  the  town-house  and  the  country-house,  either  by 
people,  clothes,  or  letter.  We  did  not  again  see  the  boy  during  his  sickness,  having 
placed  him  under  the  charge  of  another  physician. 

On  June  1,  we  were  called  to  see  the  girl,  and  found  that  she  had  scarlet  fever.  There 
were  no  other  cases  of  scarlet  fever  in  the  vicmity  of  the  country-house  where  she  had 
remained  since  leaving  the  city. 

The  boy  at  this  time  was  desquamating  freely,  and  four  days  previous  to  the  girl's 


538  PEDTATPdCS. 

being  taken  sick  a  letter  written  by  him  liad  l)eeii  sent  to  tier,  and  .-he.  atter  having  had 
it  read  to  her,  had  been  allowed  to  keep  it  under  her  pillow. 

A  careful  study  of  this  case  led  to  but  one  conclusion. — that  tlie  boy  during  the 
period  of  his  desquamation  had  infected  his  sister  at  a  distance  of  twenty  miles  by  en- 
closing the  contagium  of  scarlet  fever  in  an  envelope.  The  girl,  although  she  had  been 
in  the  same  room  with  the  boy  for  thirty-six  hours  at  the  beginning  of  the  disease,  and 
although  susceptible  to  the  disease,  had  not  contracted  it  at  that  time,  owing  to  its  very 
slightly  infectious  nature  in  its  early  stages.  On  the  other  hand,  the  stage  of  incubation 
of  scarlet  fever  being  only  a  few  days,  and  many  instances  having  proved  that  the  dis- 
ease is  very  infectious  during  its  period  of  desquamation,  it  was  evident  that  the  girl 
had  been  infected  by  means  of  the  letter. 

In  the  following  year,  on  May  20,  we  were  again  called  to  see  the  same  boy.  He  had 
been  well  in  the  morning,  but  in  the  afternoon  was  found  to  have  a  high  pulse  and  tem- 
perature, with  coryza  and  lachrymation,  so  that  it  was  deemed  best  to  send  the  sister, 
who  had  been  in  the  nursery  only  a  few  hours  with  her  brother  after  he  had  been  taken 
sick,  to  another  house,  w^hile  the  boy  w'as  absolutely  isolated.  Three  days  later  the 
boy  was  found  to  have  measles.  Ten  days  later  the  girl  was  attacked  by  measles.  This 
case  merely  emphasizes  the  now  commonly  accepted  belief  that  measles,  in  contradis- 
tinction to  scarlet  fever,  is  highly  infectious  in  the  early  stages  of  the  disease. 

Whether  the  contagium  of  scarlet  fever  can  be  carried  by  the  breath 
is  somewliat  doubtful,  but  it  is  pro])able  that  any  of  tlie  exertions  may 
contain  it.  and  that  it  is  especially  liable  to  be  transmitted  by  milk,  cloth- 
ing, toys,  books,  carpets,  and  other  articles.  Scarlet  fever  may  occur  in 
certain  animals,  and  the  contagium  may  be  transmitted  by  others,  such 
as  dogs  and  cats.  Purulent  discharges  from  the  mucous  membranes  and 
cavities,  such  as  otitis  media,  rhinitis,  empyema,  suppurating  lymph-nodes, 
pharyngitis  or  eczema,  are  infectious  and  may  prove  a  means  of  trans- 
mission of  the  disease  for  several  weeks  after  all  signs  of  desquamation 
have  ceased.  The  possDjility  is  often  disregarded  and  many  cases  dis- 
charged from  quarantine  become  the  source  of  renewed  out-breaks  of  the 
disease. 

An  instance  which  leads  me  to  believe  that  scarlet  fever  may  be  trans- 
mitted at  a  very  early  stage  of  the  disease  is  the  following : 

~~~  A  child  who  had  contracted  scarlet  fever  a  few  days  previously  came  to  a  party 
given  in  a  small  and  practically  isolated  community.  At  this  time  the  child  was  begin- 
ning to  feel  sick  and  to  complain  of  a  sore  throat.  A  spoon  which  had  been  used  by 
her  was  also  used,  before  it  was  washed,  by  one  of  the  other  children.  Six  or  seven 
days  later  this  second  child  was  attacked  by  scarlet  fever. 

A  careful  and  critical  investigation  of  the  possible  origin  of  the  second  case  re- 
sulted in  the  evidence  strongly  pointing  towards  a  direct  transmission  of  the  contagium 
from  the  mouth  of  one  child  to  that  of  the  other  by  means  of  the  spoon. 

Scarlet  fever  may  occur  at  all  ages,  but  is  rare  durmg  the  first  year  of 
life.  It  has  been  met  with  in  young  infants  who  were  nursing,  and  who 
have  proved  to  be  the  focus  of  hifection  for  a  whole  household. 

The  following  table  Avas  compiled  by  McCollom.  It  represents  the 
age  and  the  number  of  deaths  in  one  thousand  cases  of  scarlet  fever 
treated  in  the  contagious  wards  of  the  Boston  City  Hospital : 


SPECIFIC    INFECTIOUS    DISEASES. 


539 


Years. 


TABLE  60. 

One  Thousand  Cases  nf  Scarlet  Fever,  by  Ages,  with  the  Deaths. 

Deaths. 


Cases. 


Under  1  yeai-. 

1  year    .... 

2  years 

3  years 

4  years 

5  years 

6  years 

7  years 

8  years 

9  years 

10  years. .... 

11  years 

12  years 

13  years 

14  years 

15  years 

16  years 

17  years 

18  years 


9 

24 

66 

115 

99 

124 

106 

64 

62 

58 

53 

21 

20 

23 

10 

]2 

10 

7 

9 


Years. 


20 

21 


19  years 

20  years 

21  years 

22  years 

23  years 

24  years 

25  years 

26  years 

27  years 

28  years 

29  years 

30  years 

31  years 

32  years 

33  years 

34  years 

35  years 
41  years 
50  years. 


Cases. 


Deaths. 


10 


16 

9 


] 
1 
1 

1000 


1 

0 

Q 

0 
0 
0 
0 
0 

1 

1 

0 
0 
0 
0 
0 
0 
0 
0 
0 

98 


Pathological  Anatomy. — The  organs  primarily  affected  in  scarlet  fever 
are  the  skin  and  the  throat.  The  principal  complications  which  arise  in  the 
course  of  the  disease  are  connected  with  the  car  and  cervical  glands.  The 
chief  sequela,  and  the  only  one  which  is  at  all  common,  is  nephritis. 
Cardiac  disease  may  occur,  but  is  commonly  secondary  to  the  neplu'itis. 

Lesions  of  the  other  organs  are  somewhat  unusual  and  have  no  defi- 
nite connection  with  the  scarlet  fever.  They  are  generally  due  partly  to 
the  fever,  partly  to  the  septic  processes  which  have  arisen  in  the  course 
of  the  disease,  and  are  essentially  those  of  acute  inflammation  with  cehu- 
lar  exudation,  and  with  focal  necrosis  of  the  liver  and  kidneys.  The 
changes  are  a  marked  infiltration  of  leucocytes  in  the  tongue  and  in  the 
desquamating  skin.  The  internal  organs  show  an  infiltration  with  plasma- 
cells,  and  this  is  especially  noticeable  in  the  kidney  in  the  acute  interstitial 
form  of  nephritis.  A  proliferation  of  cells  is  found  in  the  follicles  of  the 
lymph-nodes,  and  these  cells  are  also  often  found  infiltrating  the  coats  of 
the  veins,  seeming  in  many  places  only  to  penetrate  the  endothelium  and 
forming  plugs  in  some  of  the  smaller  vessels.  Hyperplasia  of  the  lymph- 
nodes  is  a  constant  and  marked  characteristic.  As  a  rule,  the  spleen  is 
enlarged  and  shows  marked  follicular  hyperplasia.     (Pearce.) 

Skin. — Macroscopically  the  morbid  conditions  of  the  skin  in  scarlet 
fever,  although  varymg  in  their  manifestations,  are  usually  represented  by 
an  intense  general  erythema  covered  thickly  with  minute  macules,  which 
are  of  a  darker  red  than  the  accompanying  hyperaemia.  Minute  white 
spots  may  also  appear  thickly  scattered  over  the  reddened  surface,  prob- 
ably arising  from  areas  of  unaffected  skin  existing  in  the   midst  of  the 


540  PEDIATRICS. 

general  hyperaemia.  An  appearance  like  that  of  milium  is  also  at  times 
noticed  to  be  scattered  on  the  areas  of  skin  affected  by  the  erythema. 
No  evidence  of  this  hypersemic  condition,  which  is  so  pronounced  during 
life,  is  found  after  death. 

According  to  Neumann,  microscopic  examinations  of  the  skin  by 
means  of  hardened  sections  of  specimens  from  cases  of  scarlet  fever  and 
measles  in  the  stage  of  desquamation  explain  in  a  measure  why  the 
former  is  so  much  more  likely  to  be  infectious  during  its  stage  of  desqua- 
mation than  is  the  latter.  In  contradistinction  to  the  pathological  pro- 
cesses which  are  found  in  the  skin  in  measles,  and  which  affect  chiefly 
the  blood-vessels  and  glands,  a  very  different  picture  is  presented  on 
examination  of  sections  of  skin  taken  from  cases  of  scarlet  fever.  In  the 
latter  we  find  the  pathological  process  represented  especially  by  exudative 
cells,  which  are  very  numerous  and  closely  packed  together,  reaching 
even  up  to  the  horny  layer  of  the  epidermis.  Occasionally  these  exudative 
cells  may  finally  take  the  place  of  the  epidermal  cells,  appearing  on  the  free 
surface  of  the  skin,  and  are  gathered  thickly  among  the  excretory  ducts 
of  the  cutaneous  follicles.  It  is  thus  readily  understood  why  the  tissue 
proper  of  the  skin  and  its  epidermis  present  no  marked  changes  in  measles, 
and  why  the  epidermal  cells  are  far  less  likely  to  carry  the  contagium  than 
in  scarlet  fever,  in  which  the  possibility  of  contagium  exists  until  the  des- 
quamation has  entirely  ceased. 

Throat. — The  earliest  lesions  of  scarlet  fever  appear  on  the  mucous 
membrane  of  the  hard  and  the  soft  palate.  This  appearance  is  very 
similar  to  the  efflorescence  which  is  seen  on  the  skin,  except  that  the 
minute  white  spots  do  not  appear  on  the  congested  mucous  membrane. 
Forchheimer  states  that  the  enanthem  of  scarlet  fever  appears  from  twelve 
to  twenty-four  hours  before  the  efflorescence  ;  it  appears  upon  the  pillars 
of  the  fauces  in  the  form  of  the  characteristic  puncta,  then  rapidly  spreads 
over  the  mouth  in  the  form  of  a  scarlet-red  coalescing  efflorescence,  which 
finally  ends  in  desquamation,  producing  the  strawberry  tongue,  and  lasting 
well  into  the  second  week  of  the  disease.  These  pathological  conditions 
which  occur  in  the  throat  in  scarlet  fever  may  either  be  simply  catarrhal, 
or  result  in  one  of  the  more  severe  inflammatory  conditions  affecting  the 
tonsils,  the  pharynx,  and  the  larynx. 

The  tonsils  are  uniformly  and  extremely  bright  red,  and  are  thus  to 
be  differentiated  from  their  dusky  red  color  in  cases  of  diphtheria  before 
the  membrane  has  appeared.  On  the  hard  and  soft  palate  a  punctate 
efflorescence  is  seen,  and  this  appearance  in  from  twenty-four  to  forty- 
eight  hours  may  assume  a  yellowish  color  not  ordinarily  seen  in  catarrhal 
conditions  of  the  throat  or  in  diphtheria. 

When  a  membrane  is  seen  it  is  impossible  without  a  culture  to  differ- 
entiate conclusively  from  diphtheria.  In  many  cases,  however,  we  can 
make  a  fair  diagnosis  by  the  color  of  the  membrane  in  scarlet  fever  being 
whiter  and  the  thickness  less,  as  a  rule,  than  in  diphtheria. 


SPECIFIC    IXFECTIOUS    DISEASES.  541 

As  is  stated  by  Delafield  and  Prudden,  one  of  the  most  marked 
features  of  scarlet  fever  is  the  predisposition  which  it  entails  to  the  incur- 
sion of  pathogenic  germs  other  than  those  which  we  believe  to  cause  this 
disease.  Thus,  in  addition  to  the  inflammatory  lesions  produced  by  the 
scarlet  fever  organism  an  acute  exudative  inflaunnation  of  tlie  mucous 
membrane  may  occur,  and  may  be  associated  with  them.  This  is  appa- 
rently caused  by  the  growth  of  a  streptococcus  which,  according  to  Welch, 
in  morphological  and  biological  character  seems  to  be  identical  with  the 
dreptococcus  pyor/enes.  In  these  cases  there  may  be  much  or  little  fibrinous 
exudate,  and  there  may  be  none  at  all  in  the  early  stages,  or  even  through 
the  whole  course  of  the  affection.  The  pellicle  when  formed  may  be 
more  or  less  adherent,  and  sharply  circumscribed,  or  it  may  tend  to  spread. 
The  submucous  tissue  may  show  little  change,  or  much  congestion  and 
oedema,  or  it  may  be  the  seat  of  suppurative  inflammation.  The  entire 
process  may  be  confined  to  the  tonsils.  While  under  these  varying  con- 
ditions the  inflammatory  process  is  usually  a  local  one  and  runs  its 
course,  with  or  without  the  symptoms  of  septictBmia.  occasionally  the 
streptococcus  finds  access  to  the  blood  and  may  induce  the  lesions  of 
pyoemia.  On  the  other  hand,  it  may  by  inhalation  gain  access  to  the 
lungs  and  induce  varying  phases  of  complicating  broncho-pnemnonia. 
The  staphylococcus  pyogenes  is  not  infrequently  associated  with  the  strep- 
tococcus in  these  lesions,  but  it  is  not  apparently  of  great  significance. 
Simulating  very  closely  as  it  does  in  many  cases  both  the  local  and  the 
general  phenomena  of  diphtheria,  this  pseudo-membranous  condition  was 
formerly  confounded  with  it,  but  it  is  now  recognized  as  a  distinct 
disease. 

There  have  been  a  number  of  extended  investigations  made  on  what 
are  called  the  pseudo-membranous  inflammations  of  the  throat  in  scarlet 
fever.  Booker  has  reported  eleven  cases  of  pseudo-membranous  angina 
(t^vo  fatal)  complicating  scarlet  fever,  and  one  case  of  simple  angina  %^-ith- 
out  exanthem  in  a  family  three  members  of  which  had  scarlet  fever.  In 
all  these  cases,  as  well  as  in  four  scarlatinal  anginas  without  pseudo-mem- 
branes, Booker  found  streptococci  as  the  predominant  organism,  and  in 
none  was  the  Klebs-Loeffier  bacillus  present.  The  staphylococcus  aureus 
was  found  in  eleven  cases  without  apparent  influence  on  the  severity  of 
the  disease.  No  difference  was  observed  between  the  early  and  the  late 
pseudo-membranous  anginas  in  regard  to  the  bacteria  present.  Booker 
describes  with  much  detail  the  morphological  and  bacteriological  charac- 
teristics of  the  streptococci  found,  and  divides  them  into  groups. 

Park,  in  a  series  of  one  hundred  and  fifty-nine  cases,  reports  nineteen 
cases  of  pseudo-membranous  inflammation  of  the  throat  complicating 
scarlet  fever.  In  seventeen  of  these  cases  streptococci  predominated, 
and  in  only  two  was  the  Klebs-Loeffler  bacillus  present.  ■  Staphylococci 
were  found  in  only  a  few  cases.  Williams  has  also  reported  cases  of  this 
kind,  and  Morse  has  reported  ninety-nine  cases  of  pseudo-membranous 


542  PEDIATRICS. 

inflammation  of  the  throat  compHcating  scarlet  fever.  The  Klebs-Loeftler 
baciUus  was  found  in  twenty-three,  with  a  mortality  of  forty-three  per 
cent.,  and  was  not  found  in  seventy-six,  with  a  mortality  of  twenty-one 
per  cent. 

Finally,  we  may  conclude  that  in  scarlet  fever  the  mucous  membrane 
of  the  throat  is  rendered  peculiarly  vulnerable  to  the  invasion  of  patho- 
genic germs.  When  the  morbid  condition  in  the  throat  is  represented  hy 
a  pseudo-membrane  it  will  be  found  that  in  the  great  majority  of  cases 
the  process,  as  stated  by  Welch,  is  due  to  streptococci ;  but  when  diph- 
theria is  prevalent  and  the  opportunities  are  favorable  for  exposure,  a 
large  portion  of  the  pseudo-membranous  cases  may  be  due  to  the  Klebs- 
Loeftler  bacillus. 

In  addition  to  the  lesions  of  the  throat  just  described,  the  micro- 
organism of  scarlet  fever  may  attack  the  nasopharynx.  In  this  way,  and 
by  direct  extension  through  the  Eustachian  tubes,  secondary  aural  lesions 
may  be  produced.  The  morbid  changes  in  the  mucous  membrane  of  the 
nasopharynx  which  thus  take  place  may  result  in  a  thickening  of  the 
tissues,  which  in  some  cases  lasts  for  many  months  after  the  scarlet 
fever  has  run  its  course. 

£ar. — The  pathological  condition  of  the  ear  ^\dlich  is  most  commonly 
met  with  in  scarlet  fever  is  an  acute  inflammation  of  the  middle  ear.  This 
inflammation  is  likely  to  result  m  destruction  of  tissue,  the  formation  of 
adhesions,  tlie  establishment  of  a  long  continued  suppurative  process,  and 
an  accompanying  necrosis. 

According  to  Downie  the  influence  of  scarlet  fever  in  the  causation  of 
otitis  media  is  very  great.  He,  in  an  analysis  of  501  cases  of  chronic 
inflammation  of  the  middle  ear  treated  in  the  Children's  Hospital,  Glas- 
gow, gives  the  following  figures  :  Of  the  501  cases,  63  or  12.6  per  cent,  were 
caused  by  scarlet  fever.  Finlayson  says  that  this  symptom  was  present  in 
10  per  cent,  of  4339  cases  of  scarlet  feA^er  observed  by  him.  Caiger  found 
otitis  media  in  11  per  cent,  of  4015  cases.  Burckhart  noticed  this  con- 
dition in  33  per  cent,  of  his  cases.  At  the  South  Department  of  the 
/^^oston  City  Hospital  in  5000  cases  of  scarlet  fever  the  percentage  of 
middle  ear  trouble  was  18.  This  condition  may  appear  as  early  as  the 
fourth  day  of  the  disease  or  it  may  be  delayed  until  the  fortieth  day. 

When  there  are  severe  throat  symptoms  the  rate  of  involvement  of  the 
middle  ear  may  be  as  high  as  50  per  cent.  In  different  epidemics  of 
scarlet  fever  the  proportion  of  middle  ear  involvement  varies  greatly.  The 
septic  type  of  scarlet  fever  characterized  by  a  profuse  nasal  discharge  and 
marked  anginose  symptoms  is  almost  always  complicated  with  otitis 
media,  Wlien  the  trouble  Avith  the  middle  ear  appears  early  in  the  course 
of  an  attack  of  scarlet  fever  of  a  severe  type  the  temperature  does  not 
seem  to  be  specially  influenced.  An  attack  of  otitis  media  occurring  late 
in  the  course  of  scarlet  fever  or  during  the  convalescent  stage  is  always 
accompanied  by  a  sharp  rise  in  temperature  and  severe  pain  in  the  ear. 


SPECIFIC    INFECTIOUS   DISEASES.  543 

In  very  young  children  persistent  crying  without  apparent  cause  and  a 
constant  movement  of  the  liand  to  the  ear  are  indications  of  a  commenc- 
ing otitis  media.  At  the  South  Department,  of  50  cases  of  middle  ear 
disease  the  days  on  which  the  discharge  commenced  were  as  follows : 
Three  on  the  fourth  day  ;  seven  on  the  fifth  day  ;  eight  on  the  seventh  day  ; 
eight  on  the  ninth  day  ;  three  on  the  eleventh  day  ;  four  on  the  thirteenth 
day;  two  on  the  fourteenth  day;  two  on  the  sixteenth  day;  two  on  the  nine- 
teenth day  ;  one  on  the  twentieth  day  ;  three  on  the  twenty-second  day  ; 
two  on  the  twenty-third  day  ;  one  on  the  thirty-second  day  ;  two  on  the 
thirty-fifth  day  ;  one  on  the  thirty-eighth  day  ;  and  one  on  the  fortieth  day. 

Cultures  taken  from  the  discharge  in  a  comparatively  small  proportion 
of  instances  showed  the  presence .  of  the  streptococcus  pyogenes.  The 
most  frec{uent  organisms,  however,  were  the  staphylococcus  pyogenes 
aureus  and  citreus.  The  micrococcus  tetrageiius  was  found  in  a  very 
small  number  of  cases.  The  pneumococcus  of  Frankel  vras  occasionally 
found.  No  prognosis  so  far  as  subsequent  mastoiditis  is  concerned  can  be 
made,  based  on  the  bacteriological  findings  in  otitis  media  occurring  in  the 
course  of  scarlet  fever. 

Mastoiditis  in  scarlet  fever  is  sometimes,  although  rarely,  subsequent 
to  otitis  media.  Of  5000  cases  of  scarlet  fever  at  the  South  Department 
there  was  inflammation  of  the  mastoid  cells  in  about  0.8  of  one  per  cent. 
An  early  operation  was  advised  in  each  case  and  the  results  were  satisfac- 
tory ;  no  deaths  having  occurred  from  the  operation.  In  some  instances 
where  there  was  no  distinct  mastoid  tenderness,  but  a  slight  unexplained 
rise  in  temperature  and  a  profuse  aural  discharge,  opening  of  the  mastoid 
cells  was  earnestly  advised.  In  every  case  where  the  operation  was  per- 
formed, where  the  conditions  were  such  as  has  just  been  described,  the 
cessation  of  the  discharge  and  the  improvement  in  the  condition  of  the 
patient  was  very  marked. 

Some  physicians  have  been  inclined  to  postpone  operative  interference 
in  mastoiditis  in  scarlet  fever  on  the  ground  that  there  was  danger  of 
sepsis,  if  the  operation  Avas  performed  in  a  scarlet  fever  ward.  Others 
have  been  inclined  to  postpone  operation  until  the  process  of  desquama- 
tion was  completed.  So  far  as  my  experience  goes,  if  there  is  a  profuse 
discharge  from  the  ear,  if  there  is  marked  mastoid  tenderness,  there  is  no 
reason  for  postponing  the  operation.  It  has  been  our  experience  at  the 
South  Department  that  although  the  symptoms  referable  to  the  mastoid 
region  were  somewhat  vague  and  indefinite,  if  there  was  a  profuse  dis- 
charge from  the  ear  the  condition  of  the  mastoid  cells  and  the  adjacent 
structures  was  much  more  serious  than  would  have  been  expected  from 
the  symptoms.  In  no  instance  has  death  been  caused  by  the  operation, 
but  in  each  and  every  case  there  has  been  marked  improvement  in  the 
condition  of  the  patient  immediately  after  the  operation. 

In  cultures  from  the  mastoid  cells  the  usual  pus  cocci,  the  streptococ- 
cus pyogenes,  the  pneumococcus,  the  micrococcus  tetragenus,  and  in  two 


544  PEDIATRICS. 

instances  a  bacillus  morphologically  similar  to  the  bacillus  of  diphtheria, 
but  with  a  different  life  history  were  found.  These  different  organisms 
were  of  no  significance  so  far  as  prognosis  is  concerned,  as  all  the  patients 
did  well ;  those  in  whom  streptococci  were  found  as  well  as  those  in  whom 
pneumococci  were  detected.  This  experience  is  somewhat  at  variance 
with  that  of  others,  as  some  observers  have  laid  considerable  stress  upon 
the  presence  of  pneumococci,  so  far  as  an  unfavorable  result  is  concerned. 

Cervical  Lyn.ph-Nodes. — There  may  be  hyperplasia  of  the  cervical 
lymph-nodes.  This  condition  is  sometimes  accompanied  by  inflammatory 
oedema  of  the  tissues  of  the  neck,  which  may  go  on  to  suppuration  and 
even  to  gangrene.  In  these  cases  streptococci  are  found  in  the  glands  and 
in  the  areas  of  suppuration.  The  infection  is  supposed  to  originate  in  the 
throat.  The  entailed  glands  are,  as  a  rule,  indicative  of  secondary  or 
mixed  infection,  although  it  is  possible  that  the  slighter  forms  of  enlarge- 
ment may  be  due  to  reflex  irritation  with  resulting  hyperi3lasia  from  the 
scarlet  fever  contagium.  In  the  severe  form  the  glands  are  at  times  very 
much  enlarged,  and  when  a  gangrenous  process  results  the  blood-vessels 
may  be  affected  to  such  an  extent  as  to  be  ruptured. 

Kidney. — In  scarlet  fever,  as  in  a  number  of  other  infectious  diseases, 
there  are  certain  poisons  produced  in  the  course  of  the  disease  which  are 
probably  soluble  in  character.  The  results  of  bacteriological  cultures  in 
scarlet  fever  have  shown  that  in  a  number  of  cases  there  is  a  general  strep- 
tococcus infection,  the  infection  probably  coming  from  the  lesions  in  the 
pharynx.  In  these  cases  of  general  infection  streptococci  may  be  culti- 
tivated  from  most  of  the  organs  of  the  body,  there  being  a  general  septi- 
cgemia.  In  a  number  of  these  cases  extensive  lesions  may  be  found  in 
the  kidneys,  and  yet  these  lesions  may  bear  no  relation  whatever  to  the 
presence  or  absence  of  streptococci.  In  like  manner,  streptococci  may  be 
found  in  the  kidney  without  any  lesion  of  the  kidney.  These  lesions  are 
diffuse,  and  affect  both  kidneys  and  all  parts  of  the  kidney.  From  the 
best  evidence  which  we  have  it  would  seem  that  the  wus,  or  whatever  it 
is  which  produces  the  lesions  in  the  kidney,  is  not  a  living  organism,  but  is  a 
soluble  chemical  poison  produced  by  the  organisms  of  scarlet  fever,  or  by 
other  organisms  located  in  some  other  part  of  the  body.  This  soluble 
poison  when  produced  elsewhere  is  taken  locally  into  the  blood  and  affects 
various  parts  of  the  economy.  In  post-mortem  examinations  of  scarlet 
fever  certain  lesions  ^^ill  usually  be  found  in  the  kidneys. 

These  lesions,  according  to  Councilman,  may  be  divided  into  two 
classes,  (1)  represented  by  simple  degeneration  of  the  epithelium,  and  (2) 
represented  by  marked  changes  m  the  tissues  of  the  kidney. 

In  i\ie  first  class  of  cases  the  soluble  poison  may  only  affect  the  integ- 
rity of  the  capsular  epithelial  cells  of  the  glomeruH.  The  poison  may 
produce  certain  degenerative  changes  in  these,  but  need  not  be  accompa- 
nied by  any  proliferation  of  cells,  or  by  any  condition  which  would  be 
characterized  as  inflammator}'.     It  is  more  than  probable  that  these  sim- 


SPECIFIC   IXFECTIOUS   DISEASES.  545 

pie  degenerative  lesions  are  accompanied  during  life  by  evidence  of  albu- 
minuria, and  in  case  death  takes  place  there  may  be  no  macroscopic 
evidence  of  any  lesions  in  the  kidneys.  Careful  microscopic  examination, 
however,  will  show  a  condition  of  degeneration  in  the  capsular  epithelium 
of  the  glomeruli.  Associated  with  this  there  will  usually  be  found  cloudy 
swellmg  of  various  degrees  of  mtensity  in  the  cells  of  the  convoluted  and 
the  smaller  collecting  tubules.  The  degeneration  here  is  rarely  of  a  fatty 
character.  Clinically,  in  the  purely  degenerative  changes  there  may  be 
only  albmninuria  with  the  presence  of  faint  hyaline  casts,  and  here  and 
there  a  few  leueocji;es. 

In  the  second  class,  owing  to  a  greater  intensity  in  the  action  of  the 
poison,  or  to  some  possible  difference  in  its  character,  more  marked  changes 
may  take  place  in  the  kidney,  and  may  be  accompanied  by  the  degenera- 
tive lesions  which  are  distinctive  of  the  first  class.  Different  forms  of 
lesions  may  occur  in  the  second  class,  and,  according  to  the  predominance 
of  one  form  over  the  other,  may  characterize  a  special  form  of  renal  dis- 
ease. These  lesions  may  be  divided  according  to  their  anatomical  distri- 
bution into  interstitial,  in  which  there  is  marked  jDroliferation  of  the  inter- 
stitial tissue  of  the  kidney,  and  glomerular,  m  which  the  lesions  are  chiefly 
confined  to  the  glomerulus  and  its  capsule. 

In  the  interstitial  form  there  will  be  found  in  the  interstitial  tissue  be- 
tween the  tubules  accumulations  of  cells,  the  source  of  which  is  not  clear, 
although  they  probably  come  from  the  blood.  Most  of  these  cells  have 
the  character  of  plasma-cells,  but  among  them  are  a  few  lymphoid  cells 
and  polynuclear  leucoc}i;es.  This  form  of  nephritis  should  be  considered 
as  purely  interstitial,  smce  its  lesions  are  in  no  way  related  to  those  of  the 
epithelial  tissue.  There  is  both  a  general  and  a  focal  infiltration  of  cells 
in  the  interstitial  tissue.  The  focal  infiltration  is  found  principally  in  the 
cortex  of  the  kichiey  and  about  the  glomeruli,  the  glomerulus  frec{uently 
appearing  as  a  centre  from  which  the  infiltration  extends  into  the  intersti- 
tial tissue  between  it  and  the  surrounding  tubules. 

This  form  of  nephritis  was  first  described  by  Wagner  as  the  lymphoid 
kidney.  The  kidney,  macroscopically,  is  swollen  ;  the  capsule  is  easily 
stripped  from  the  cortex,  and  is  moist,  whitish,  and  opaque.  Usually  there 
is  no  evidence  of  hemorrhage,  although  in  some  cases  points  of  punctiforra 
hemorrhage  may  be  found  in  the  cortex  and  m  the  intermediate  zone. 

Clinically,  in  this  form  there  may  be  little  evidence  of  the  severity  of 
the  lesions.  There  may  be,  however,  albuminuria  corresponding  to  what 
is  seen  in  the  purely  degenerative  class.  The  quantity  of  the  urine  may 
be  very  little  diminished,  and  casts  may  be  present,  as  well  as  a  certain 
number  of  desquamative  epithelial  cells  and  leucocytes. 

These  lesions  are  not  confined  to  scarlet  fever,  but  may  be  found  in 
diphtheria,  in  measles,  and  in  other  infectious  diseases  of  children,  but  they 
are  not  common  in  the  infectious  diseases  of  adults. 

Fig.  125  represents  a  microscopic  section,  made  by  Councilman,  and  is 


54G  PEDIATRICS. 

a  good  example  of  these  interstitial  lesions  in  scarlatinal  nephritis.  The 
section  was  taken  from  a  case  of  pure  scarlet  fever.  There  \vas  no 
anuria  and  no  dropsy.  The  kidneys  were  enlarged,  whitish,  and  without 
hemorrhage.  Cultures  from  this  case  gave  a  general  infection  with  strep- 
tococci in  all  the  organs  except  the  kidney,  and  yet  the  kidneys,  notwith- 
standing the  extent  of  their  lesions,  were  found  to  bo  free  from  strepto- 
cocci.    The  epithelium  of  the  tubules  was  somewhat  swollen.     The  tubules 


Fig.  Vlh 


f'ups^-^     ^-f^y^^-^.   -^ 


?4 


Interstitial  nephritis.    Section  of  kidney  from   child  with  scarlet  fever.     (Hartnack,  ocular  Xo.  II. 

objective  No.  VIII.    Tube  closed.) 

themselves  Avere  slightly  dilated,  and  the  epithelium  was  more  granular  than 
normal.  The  interstitial  tissue  was  much  more  extensive  than  normal. 
The  spaces  between  the  tubules  were  increased  both  by  cedema  and  by 
^-^lular  infiltration.  In  the  interstitial  tissue  blood-vessels  were  seen  filled 
with  cells  of  the  same  character  as  those  outside.  It  is  probable  that  most 
of  the  cells  outside  the  vessels  came  from  proliferation  of  the  cells  of  the 
blood-vessels.  The  round  spaces  in  the  interstitial  tissue  represent  blood- 
vessels. 

Another  form  of  nephritis,  called  the  glomerular,  is  much  more  fre- 
quently found  in  scarlet  fever  than  in  any  other  of  the  acute  infectious  dis- 
eases of  children,  but  is  not  so  common  as  the  acute  interstitial  form.  In 
this  glomerular  form  the  chief  lesion  of  the  disease  consists  essentially  in  a 
proliferation  of  the  capsular  epithelium  combined  with  hyperplasia  of  the 
connective  tissue. 

The  proliferation  of  the  capsular  epithelium  leads  to  the  furmatioii  of 
masses  of  cells  within  the  capsule  between  the  glomerular  capillaries  and 


SPECIFIC    LXFECTIOUS    DISEASES. 


547 


the  capsule.  These  cells  evidently  result  from  the  prohfe ration  of  the 
capsular  epithelium.  As  a  result  of  this  there  may  be  greatly  increased 
pressure  on  the  vessels  of  the  glomerulus,  possibly  with  an  obliteration 
of  these  vessels.  The  cellular  infiltration  in  the  interstitial  tissue  is  not 
so  extensive  as  in  the  other  form.  Accompanying  these  changes  in  the 
glomerulus  tliere  is  almost  always  more  or  less  hemorrhage  botli  in  the 
tubules  and  in  the  interstitial  tissue. 

Fig.  126  represents  a  section  made  by  Councilman  of  glomerular  ne- 
phritis. This  section  was  taken  from  a  case  of  scarlet  fever  complicated 
by  glomerulo-nephritis.     In  the  centre  of  the  field  a  glomerulus  is  seen, 

Fig.  126. 


^     ^   %  ® 

\  z^; 


Capsular  glcmerulo  i-ephntis.    Section  of  kidnev  irom  child  \s\X.\\  searkt  fL\er.     .  Hartna^k,  ovular  No. 
II.,  objective  No.  VIII.    Tube  closed.) 


with  an  infiltration  of  cells  in  the  capsular  space.  The  capsular  cells  are 
oval  and  distinctly  epithelial  in  character.  Cellular  proliferation  of  the 
cells  having  generally  the  character  of  those  in  the  section  of  interstitial 
nephritis  (Fig.  125)  is  to  be  seen  in  the  interstitial  tissue.  In  the  tubule 
at  the  letl  upper  corner  there  is  evidence  of  hemorrhage,  and  some  hemor- 
rhage is  also  to  be  noticed  in  the  interstitial  tissue  on  the  right  of  the 
specmien.     In  this  case  the  anuria  and  dropsy  were  extreme. 

This  form  of  nephritis  may  be  best  designated  as  capsular  glomerulo- 
nephritis. The  kidney  is  swollen  and  much  more  hypersemic  than  in  the 
interstitial  form.     The  markmgs  of  the  cortex  either  are  obscured  or  can- 


548  PEDIATRICS. 

not  be  made  out  at  all,  and  there  are  numerous  areas  of  hemorrhage  and 
hypertemia,  giving  a  kidney  a  mottled  appearance. 

It  is  this  capsular  glomerulo-nephritis  which  gives  the  most  marked 
clinical  evidence  of  the  extent  of  the  lesions  in  the  kidney.  In  this  form 
dropsy  is  almost  always  present,  the  amount  of  urine  is  greatly  dimin- 
ished, and  in  the  more  severe  cases  there  may  be  complete  anuria. 
Blood-casts  are  found  more  frequently  in  the  urine  than  in  the  interstitial 
form.  The  diminution  in  the  amount  of  the  urine  points  to  involvement 
of  the  glomerulus.  Even  severe  cases  of  this  form  may  be  recovered 
from.  The  process  of  cell-proliferation  may  cease,  the  cells  formed  in 
the  capsular  space  may  disappear  and  pass  out,  and  the  kidney  in  after- 
years  may  show  few  or  no  evidences  of  the  process  through  which  it  has 
passed.  In  a  certain  number  of  cases,  however,  from  this  form  of  nephritis 
a  chronic  nephritis  is  developed.  Cases  of  this  kind  have  been  reported, 
notably  one  by  Aufrecht. 

In  both  the  interstitial  and  the  capsular  glomerulo-nephritis  fatty  de- 
generation of  the  epithelium  is  not  found  to  any  degree.  The  epithelium 
is  frequently  swollen  and  granular,  and  may  be  hyaline. 

These  two  forms  of  nephritis  should  be  separated  from  each  other, 
although  transitions  between  their  lesions  are  found.  Usually  they  can  be 
distinguished  microscopically. 

We  can,  therefore,  recognize  three  pathological  conditions  of  the  kid- 
ney in  scarlet  fever :  first,  the  purely  degeneratice  ;  second,  the  acute  inter- 
stitial;  and  third,  the  capsular  glomerular. 

Heart. — The  pathological  conditions  of  the  heart  which  are  at  times 
found  in  scarlet  fever  do  not  differ  in  their  macroscopic  appearances  from 
those  met  with  in  other  diseases.  Cardiac  disease  occurring  in  the  course 
of  scarlet  fever  may  arise  in  two  ^vays  :  (1)  from  the  general  septic  con- 
dition existing  during  the  period  of  the  height  of  the  temperature  and 
general  efflorescence,  and  represented  usually  by  an  endocarditis ;  (2)  at 
a  much  later  period  from  a  nephritis  which  has  arisen  as  a  complication, 
Tind  following  ^^■hich.  from  the  resulting  increased  blood-pressure,  en- 
largement of  the  heart  has  been  produced,  which  may  be  represented  by 
hypertrophy  or  by  dilatation,  or  by  both. 

In  connection  with  this  subject.  Silbermann  has  found  on  examining 
a  lai^e  number  of  cases  of  nephritis  during  attacks  of  scarlet  fever  a 
decided  hypertrophy  of  the  heart  combined  with  dilatation.  In  some 
cases  both  sides  of  the  heart  were  equally  affected,  but  usually  only  the 
left  side  was  involved.  In  only  a  few  cases  was  there  found  a  partial 
fatty  degeneration  of  the  nmscular  fibres ;  the  endocardium,  pericardium, 
and  blood-vessels  were  normal.  According  to  Silbermann's  observations, 
the  cardiac  affection  was  related  to  the  post-scarlatinal  nephritis,  and  not 
to  the  scarlet  fever  process  itself,  as  the  hypertropliy  was  never  found 
when  the  child  died  in  the  early  weeks  of  the  scarlet  fever.  He  calls  atten- 
tion to  the  sliort  period  wliich  intervened  between  the  first  appearance  of 


SPECIFIC   INFECTIOUS   DISEASES.  549 

the  nephritis  and  the  consecutive  heart  hypertropliy.  in  many  cases  the 
time  not  being  much  longer  than  a  week.  He  also  noticed  that  in  the 
cases  in  which  hypertrophy  and  rapid  dilatation  followed  the  acute  ne- 
phritis of  scarlet  fever  the  ages  of  the  children  were  three  and  a  half. 
four.  five,  and  six  years,  and  the  post-scarlatinal  cardiac  enlargement 
corresponds  to  the  physiological  hypertrophy  referred  to  on  page  84. 

Blood. — The  Avork  done  at  the  South  Department  of  the  Boston  City 
Hospital  by  Tileston  and  Locke  shows  that  in  all  the  very  mild  cases  there 
is  a  slight  secondary  anaemia.  A  hyperleucocytosis  almost  invariably 
occurs.  The  count  rises  abruptly  on  the  second  to  the  eighth  day  (18.000 
to  40.000  per  cm.),  falls  rapidly  for  a  few  days,  then  gradually  to  normal 
m  convalescence,  which  is  usually  at  the  end  of  from  three  to  six  weeks. 
During  the  stages  of  prodroma  and  efflorescence  the  polynuclear  leuco- 
cytes are  both  relatively  and  absolutely  increased,  but  decrease  gradually 
with  the  fall  in  the  leucocytosis  until  convalescence,  when  they  may  be- 
come relatively  though  never  absolutely  below  normal.  The  mononuc- 
lears take  an  exactly  opposite  course. 

The  eosinophi'es  disappear  entirely  at  the  onset,  or  are  greatly  reduced, 
to  rise  above  normal  when  defervescence  begins.  This  eosinophilia  persists 
until  late  convalescence. 

Complications,  with  a  few  exceptions,  exert  no  influence  upon  the 
blood,  unless  very  severe,  as  in  the  case  of  nephritis  and  diphtheria,  when 
they  may  cause  an-  increase  in  the  leucocytosis.  Very  virulent  cases  of 
scarlet  fever  may  cause  a  low  white  count,  but  this  does  not  necessarily 
indicate  a  fatal  termination. 

IxcuBATiox. — The  stage  of  incubation  of  scarlet  fever  is  micertain  and 
iiTegular.  but.  as  a  rule,  it  is  shorter  than  that  of  any  of  the  other  ex- 
anthemata. It  is  usualh'  less  than  seven  days,  and  (juitc  frer|uently  it  is 
only  trom  two  to  four  days. 

Variations  ix  the  Type  of  Disease. — Scarlet  fever  may  be  divided  into 
two  forms,  the  benign  form  and  the  malignant  form.  The  difference  in 
the  symptoms  of  the  common,  or  benign,  form  of  the  disease  from  those 
of  the  rare,  or  malignant,  form  is  very  striking.  They  could  well  be 
classified  as  entirely  separate  diseases,  were  it  not  that  the  contagium  has 
been  proved  to  be  the  same  in  each,  by  the  fact  that  one  form  of  the  dis- 
ease may  give  rise  to  the  other  m  different  individuals.  It  seems  as 
though  it  were  more  the  susceptibility  of  tlie  individual  to  the  scarlet 
fever  contagium  than  tlie  contagium  itself  wliicli  produces  a  greater  or 
less  severity  of  the  symptoms. 

BKNIGN   FORM   OF   SOABLET   FEVER. 

The  benign  form  of  scarlet  fever  either  runs  a  simple  tA-pical  course  or 
is  accompanied  by  variations  and  complications,  which  makes  its  course 
irregular. 

Prodromal  Stage. — The  length  of  the  prodromal  stage  varies,  as  a  rule, 


550  PED[ATRI(^S. 

from  twelve  to  thirty-six  hours.  During  ihis  stage  tlie  temperature  con- 
tinues to  rise  somewhat,  and  at  its  end  the  efflorescence  appears  on 
the  skin. 

Symptoms. — Stage  of  Invasion. — The  invasion  of  the  disease  is  usually 
sudden,  and,  as  a  rule,  active.  The  child  feels  very  sick,  looks  dull,  com- 
plains of  sore  throat  and  nausea,  and  in  a  large  number  of  cases  vomits 
continuously.  The  vomiting  usually  ceases  in  the  stage  of  efflorescence 
and  often  before  the  prodromal  stage  has  ended.  The  pulse  is  rapid. 
The  temperature  is  high,— 39.4°,  40°,  40.5°  C.  (103°,  104°,  105°  F.). 
In  infants  and  ver}^  young  children  if  the  temperature  rises  to  40°  or 
41.1°  C.  (104°  or  106°  F.)  convulsions  are  very  likely  to  occur.  The 
higher  the  temperature  at  the  beginning  of  the  disease  the  more  active 
the  symptoms,  and  the  shorter  the  prodromal  period  the  more  severe  will 
be  the  case.  An  initial  temperature  of  40°  C.  (104°  F.)  points  towards 
a  severe  case. 

Young  children  seem  to  show  a  less  sensitive  condition  of  the  throat 
than  is  met  with  in  older  children  and  in  adults. ,  The  appearance  of  the 
mucous  membrane  of  the  throat,  although  perhaps  not  characteristic,  as 
at  times  a  simple  non-infectious  pharyngitis  may  simulate  it  quite  closely, 
is,  in  connection  with  the  general  symptoms,  at  least  suggestive.  The 
mucous  membrane  of  the  hard  and  the  soft  palate  and  of  the  pharynx  is 
much  congested.  On  the  hard  and  the  soft  palate  thickly  scattered  over 
the  reddened  surface  are  minute  macules  the  color  of  which  is  a  little 
darker  red  than  that  of  the  intervening  mucous  membrane.  This  condi- 
tion represents  the  earliest  stage  of  the  efflorescence,  which  later  appears 
on  the  skin. 

Efflorescence. — The  efflorescence  of  scarlet  fever  is  of  an  erythematous 
and  punctate  character,  sometimes  looking  as  though  minute  macules  had 
been  sprinkled  over  the  general  redness  of  the  skin.  It  starts  on  the 
front  of  the  neck  and  the  upper  part  of  the  chest,  and  rapidly  extends 
all  over  the  body  and  extremities,  and  upward  to  the  face.  This  charac- 
^ leristic  order  of  invasion  of  the  skin  aids  us  in  distinguishing  the  efflores- 
cence of  scarlet  fever  from  that  of  the  common  erythema  which  occurs 
in  such  diseases  as  pneumonia,  and  in  cases  in  which  certain  drugs,  such 
as  belladonna,  have  affected  the  skin  and  the  efflorescence  comes  out 
everywhere  at  once  and  has  an  irregular  distribution.  It  also  enables  us 
to  distinguish  the  disease  from  measles,  in  which  the  efflorescence  begins 
on  the  sides  of  the  neck  and  on  the  face  and  extends  downward.  On 
gently  drawing  the  fmger  over  the  efflorescence  of  scarlet  fever  the  result- 
ing white  mark  remains  longer  than  is  the  case  with  a  common  erythema. 
The  efflorescence  of  scarlet  fever  continues  to  extend  over  the  body  for 
two  or  three  days  after  its  first  appearance.  During  this  period  the 
tongue  is  much  reddened  and  its  papillae  appear  very  prominent,  consti- 
tuting what  has  been  called  the  "  strawberry  tongue."  This  condition  is 
to  be  distinguished  from  the  enlarged  papillae  seen  at  an  earlier  stage  of 


SPECIFIC    INFECTIOUS    DISEASES. 


551 


the  disease  on  the  tip  and  sides  of  the' tongue.  McCollom,  in  a  study  of 
one  thousand  cases,  describes  this  latter  condition  as  diagnostic  of  scarlet 
fever.     Tliere  is  at  times  in  this  stage  great  irritation  of  the  skin. 

There  may  be  slight  delirium  even  in  mild  cases  during  the  stage  of 
efflorescence.  This  delirium  may  be  very  active  and  yet  not  be  of  serious 
import,  provided  the  temperature  remains  moderate. 

The  temperature  rises  when  the  efflorescence  appears,  and  reaches  its 
maximum  at  the  end  of  the  outbreak,  in  uncomplicated  cases,  but  there 
is  no  decided  rise  just  before  or  fall  after  the  height  of  the  efflorescence 
as  is  the  case  in  measles ;  on  the  contrary,  the  temperature  slowly  di- 
minishes until  the  ninth  or  tenth  day  from  the  beginning  of  the  prodro- 
mal symptoms,  when  it  becomes  about  normal,  showing  no  decided  crisis 
such  as  is  seen  in  measles,  but  representing  a  defervescence  by  lysis. 
Chart  20  represents  the  temperature  as  it  commonly  occurs  in  cases  of 
scarlet  fever  of  the  benign  and  regular  form. 

The  pulse  is  accelerated  during  the  period  when  the  temperature  is 
elevated,  and  corresponds  to  it.     It  varies  from  120  to  160. 

Desquamation. — The  stage  of  desquamation  begins  at  about  the 
seventh  day  from  the  time  when  the  efflorescence  first  appears,  and 
in  the   parts   of  the  skin   first  attacked.     The  desquamation,  however, 


CHART 

20. 

Dai/s  o/^J?is€tzse 

F 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

c 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORMI. 
TEMP. 

98° 
97° 
96° 
95° 

M  E 

M  E 

M  E 

M   E 

M  E 

M   E 

M   E 

M   E 

M  E 

M  E 

M  E 

M  E 

416° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37  0° 

36  6° 

36.1° 
35.5° 
35.0° 

/ 

/ 

/ 

y 

y 

/ 

M 

/ 

u 

A 

/ 

v 

\/\ 

t 

/ 

V 

\y 

i 

L. 

— 

— 

... 

-- 

... 

V. 

i/ 

>— 

Benign  and  regular  form  of  scarlet  fever. 


is  not  always  proportionate  to  the  intensity  of  the  efflorescence.  It 
is  at  first  composed  of  small  particles  of  cutis,  but  these  soon  become 
larger,  and  early  in  the  third  week  from  the  beginning  of  the  disease 
they  fall  from  the  body  in  large  flakes,  and  are  most  characteristic  and 
pronounced  in  the  fingers  and  toes.     This  form  of  desquamation  is  called 


552  PEDIATRICS. 

lamellar.  Here,  again,  we  have  an  important  means  of  distinguishing 
scarlet  fever  from  measles,  for  in  measles  the  desquamation  is  almost 
universally  of  a  furfuraceous  character  throughout  the  whole  course  of 
the  disease,  while  the  characteristic  desquamation  of  scarlet  fever  is  lamel- 
lar. This  lamellar  form  of  desquamation  may,  at  times,  in  certain  indi- 
viduals, and  following  the  more  intense  inflammations  of  the  skin,  be 
represented  by  large  and  extensive  pieces  of  skin.  This  is  well  shown  in 
a  specimen  in  the  Warren  Museum,  where  large  strips  of  skin  have  come 
from  the  hand  of  a  patient  with  scarlet  fever  so  as  almost  to  form  a  glove. 

Sometimes  the  desquamation  lasts  only  ten  days,  but  it  may  continue 
for  two  or  three  weeks.  It  is  especially  slow  in  disappearing  from  the 
hands  and  feet,  and  it  may  remain  between  the  fingers  and  toes  for  a 
number  of  weeks.  Sometimes  after  the  desquamation  has  apparently 
ceased  and  the  skin  has  been  smooth  and  normal  for  several  days  it  may 
begin  again,  and  thus  prolong  the  period  of  convalescence. 

Urine. — The  urine  is  lessened  in  amount  during  the  prodromal  stage, 
returns  to  the  normal  amount  in  the  stage  of  efflorescence,  increases 
during  the  stage  of  desquamation,  amounting  at  times  to  a  polyuria,  and 
returns  again  to  the  normal  amount  at  the  end  of  this  stage.  During  the 
stage  of  efflorescence,  especially  if  the  temperature  is  considerably 
heightened,  there  may  appear  in  the  urine  a  small  amount  of  albumin, 
but  this  disappears  as  the  temperature  subsides,  is  probably  only  the 
result  of  the  fever,  as  in  many  other  diseases  accompanied  by  a  high 
temperature,  and  is  not  to  be  confounded  with  the  albuminuria  of  the 
nephritis  which  in  some  cases  complicates  the  stage  of  desquamation. 

There  is  considerable  reason  to  suppose  that  a  mild  form  of  nephritis 
accompanies  almost  every  case  of  scarlet  fever,  although  in  many  cases  no 
clinical  symptoms  pointing  towards  the  kidney  appear  and  nothing  ab- 
normal is  found  on  examination  of  the  urine. 

Diagnosis. — The  diagnosis  of  the  benign  and  typical  form  of  scarlet 
fever  is  not  difficult.  Its  incubation  is  decidedly  short  in  comparison 
^ith  that  of  any  of  the  other  exanthemata.  Its  prodromal  stage  is 
short  in  comparison  with  that  of  variola  and  measles,  and  longer  than 
the  exceedingly  brief  prodromal  stage  of  varicella.  The  characteristic 
prodromal  symptoms  of  sore  throat  and  a  general  and  intense  hypersemia 
of  the  mucous  membrane,  accompanied  by  vomiting  and  severe  constitu- 
tional symptoms,  make  it  easy  to  differentiate  it  from  measles,  varicella, 
and  variola,  none  of  which,  as  a  rule,  show  these  symptoms. 

The  punctate  erythematous  lesions  which  appear  in  the  stage  of 
efflorescence  of  scarlet  fever  are  rarely  met  with  in  any  of  the  other  dis- 
eases of  this  group.  This  efflorescence,  beginning  on  the  neck  and  chest 
and  extending  upward  and  downward,  is  distinguished  by  its  peculiar 
distribution  from  that  of  the  other  members  of  the  group. 

The  efflorescence  which  in  certain  cases  appears  after  the  use  of  anti- 
toxin may  simulate  so  closely  the  efflorescence  of  scarlet  fever  that  in  the 


SPECIFIC    INFECTIOUS   DISEASES.  553 

first  twenty-four  to  forty-eight  hours  it  cannot  be  differentiated  except 
by  the  appearance  of  the  throat.  In  this  connection  it  must  be  remem- 
bered that  the  antitoxin  efflorescence  may  appear  in  forty-eight  hours, 
and  again  not  for  three  weeks. 

The  lameUar  desquamation  is  very  characteristic,  and  is  seldom  seen 
in  any  of  the  other  exanthemata.  One  of  the  eariiest  manifestations  of 
the  desquamation  is  a  white  Hue  at  tlie  tip  of  the  fingers  at  the  junction 
of  the  nail  with  the  pulp.  These  breaks  of  the  cuticle  at  the  finger-tips 
occur  in  every  case  of  scarlet  fever,  according  to  McCollom. 

The  complications  arising  in  the  ear,  and  the  occurrence  of  nephritis 
as  a  common  sequela  in  scarlet  fever,  do  not  to  the  same  degree  find 
their  counterparts  in  varicella  and  measles. 

Prognosis. — The  prognosis  of  the  benign  and  regular  form  of  scarlet 
fever  is  in  almost  every  case  favorable.  It  is  comparatively  rare  for  the 
symptoms  to  become  sufficiently  serious  to  cause  death  unless  some  com- 
plication has  arisen  in  the  course  of  the  disease.  The  individual  who 
succumbs  to  the  simple  uncomplicated  form  of  scarlet  fever,  even  when 
the  initial  temperature  is  high  and  the  symptoms  are  severe,  as  a  rule 
must  have  been  unusually  vulnerable  to  the  toxic  effect  of  the  scarlet 
fever  contagium,  or  must  have  had  a  very  low  degree  of  vitality  at  the 
beginning  of  the  disease. 

Prophylaxis. — There  is  no  known  prophylactic  against  scarlet  fever 
except  isolation,  which  for  many  reasons  should  be  rigorously  enforced. 
We  must  remember  the  fact  that  when  the  child  has  passed  its  tenth 
year  the  chances  of  its  ever  contracting  the  disease  are  ver)^  much  lessened. 
We  must  also  appreciate  that  it  is  especially  important  to  protect  children 
who  are  learning,  or  who  have  just  learned  to  talk.  The  commonly 
occurring  and  often  intractable  form  of  otitis  which  accompanies  scarlet 
fever  may  not  only  render  the  child  deaf,  but  in  a  case  where  the  child 
has  not  learned  to  talk  it  may  lead  to  deaf-mutism.  We  should,  there- 
fore, under  all  circumstances  discountenance  the  opinion  so  often  ex- 
pressed by  the  laity,  and  sometimes  even  by  physicians,  that  it  is  well  for 
children  to  have  scarlet  fever  while  they  are  young,  on  the  ground  that 
otherwise  they  will  probably  contract  it  at  a  later  period  of  life,  when  the 
type  of  the  disease  may  be  more  severe.  The  assertion  that  the  type  of 
the  disease  is  more  severe  in  adults  than  in  children  is  not  corroborated 
by  my  experience. 

Treatment. — An  accurate  knowledge  of  the  chief  pathological  lesions 
which  occur  during  the  course  of  the  disease  enables  us  to  deduce  the 
appropriate  treatment.  By  treatment  is  not  to  be  understood  simply  the 
use  of  drugs.  On  the  contrary,  drugs  are  emjDloyed  to  entirely  too  great 
an  extent  in  a  large  proportion  of  the  uncomplicated  cases  of  the  benign 
type  of  scarlet  fever.  We  feel  that  we  can  speak  with  some  authority  on 
this  point,  as  it  has  been  our  rule  for  many  years  to  compare  the  results 
of  cases  treated  by  our  colleagues  with  drugs  with  our  own  cases  treated 


554  PEDIATRICS. 

wilhout  drugs,  and  certainly  notliing  that  we  have  observed  in  this  com- 
parison would  indicate  that  our  patients  iiad  suffered  from  want  of  treat- 
ment. We  should  have  some  definite  reason  for  what  we  do,  and  should 
not  be  influenced  by  vague  ideas  of  what  drugs  are  supposed  to  be  bene- 
ficial in  certain  diseases. 

The  treatment  of  a  case  of  scarlet  fever  is  that  of  a  self-limited  disease. 
With  our  present  knowledge  of  it,  the  disease  cannot  be  cut  short.  We 
should,  therefore,  endeavor  to  keep  it  within  its  own  limits  by  avoiding 
complications.  To  do  this  we  must  remember  which  tissues  are  affected 
as  part  of  the  disease  and  wliicli  are  likely  to  be  affected  by  complications. 

In  the  first  class  we  must  consider  the  throat  and  the  skin  ;  in  the 
second  class  the  ear  and  the  kidney. 

At  the  onset  of  the  disease  the  child,  as  a  rule,  is  so  profoundly  affected 
by  the  scarlet  fever  contagium  that  it  wishes  to  be  put  to  bed  at  once. 
The  symptoms  which  from  their  intensity  require  treatment  in  the  pro- 
dromal stage  of  the  disease  are  the  vomiting,  the  sore  throat,  and  the  high 
temperature. 

The  vomiting,  as  a  rule,  is  of  such  short  duration,  and  is  so  symp- 
tomatic of  nervous  gastric  disturbance  caused  by  the  toxic  effect  of  the 
poison,  that  it  should  be  looked  upon  as  eliminative,  and  usually  does  not 
rec|uire  the  use  of  anything  but  pieces  of  cracked  ice  to  be  held  in  the 
mouth. 

The  treatment  of  the  throat  in  scarlet  fever  is  to  be  especially  directed 
not  only  to  allaying  the  temporary  discomfort  of  the  pharyngitis,  but  also 
to  the  prevention  of  the  inflammatory  process  from  extending  through  the 
Eustachian  tube  to  the  membrana  tympani  and  producing  an  otitis  which 
may  result  in  a  meningitis.  This  latter  complication  is  rendered  possible 
by  the  close  vascular  connection  which  exists  in  infancy  and  in  childhood 
between  the  meningeal  blood-vessels  and  the  vessels  of  the  tympanum, 
through  the  open  petro-sc{uamosal  suture. 

Another  reason  for  systematically  treating  the  throat  in  all  cases  of 
/-^"scarlet  fever  is  derived  from  the  belief  that  the  various  secondary  infec- 
tions which  take  place  in  the  disease  are  probably  caused  by  the  entrance 
of  pathogenic  organisms  to  the  various  tissues  through  the  infiamecl  and 
vulnerable  mucous  membrane  of  the  pharynx.  This  invasion  is  com- 
monly of  the  cervical  glands,  the  ear,  the  lung,  the  heart,  and  the  kidney. 
If  this  belief  is  correct,  antiseptic  treatment  directed  to  the  throat  is  indi- 
cated as  possibly  preventive  of  the  complications  which  may  arise  in  the 
disease. 

For  the  purpose  not  only  of  allaying  the  irritation  of  the  throat,  but 
also  of  preventing  the  spread  of  the  morbid  process  to  the  ear,  if  possible, 
the  throat  may  be  sprayed  several  times  during  the  day.  It  is  better  not 
to  spray  the  nose  because  of  the  danger  of  causing  an  extension  of  the 
inflammatory  process  through  the  Eustachian  tubes  into  the  middle  ear. 
Solutions  (two  or  three  per  cent.)  of  borate  of  sodium  in  water  combined 


SPECIFIC    INFECTIOUS   DISEASES.  555 

Avith  a  small  amount  of  glycerin  are  useful  for  this  purpose.  A  four  per 
cent,  solution  of  boric  acid  in  water  can  also  be  used  to  advantage.  The 
local  treatment,  however,  should  always  be  of  the  mildest  form,  since  any 
additional  irritation  of  the  mucous  membrane  will  render  it  more  vulner- 
able to  the  streptococcus  invasion.  If  the  child  knows  how  to  gargle,  the 
discomfort  wliich  arises  usually  from  the  sore  throat  during  the  first  day 
or  two  of  the  disease  may  often  be  allayed  by  simply  gargling  with  cool 
water.  This  procedure  answers  a  double  purpose :  it  not  only  reduces 
somewhat  the  hypersemic  condition  of  the  mucous  membrane  of  the 
upper  part  of  the  throat  and  cleanses  the  anterior  fauces,  but  also  tends 
to  prevent  the  extension  of  the  pathogenic  organisms  which  would  neces- 
sarily be  favored  by  a  continuous  recumbent  position  of  the  child.  If  the 
child  is  unable  to  gargle,  some  pieces  of  ice  may  be  given  to  it  to  hold  in 
its  mouth,  and  it  should  occasionally  be  allowed  to  sit  up,  as  v;hen  its 
nourishment  is  being  given. 

However  desirable  this  treatment  of  the  throat  may  be  in  scarlet 
fever,  we  are  but  too  often  baffled  in  our  attempts  to  treat  them  locally, 
on  account  of  the  persistent  resistance  of  the  child. 

Chlorate  of  potash,  which  is  so  frequently  used  for  the  treatment  of 
the  throat  in  scarlet  fever,  is,  in  our  opinion,  a  drug  which  in  this  disease 
it  will  be  wiser  not  to  allow  the  child  to  swallow,  on  account  of  its  pos- 
sible deleterious  action  on  the  kidney,  which  from  the  beginning  of  the  dis- 
ease to  its  end  is  in  so  sensitive  a  condition  as  to  be  readily  affected  by 
any  irritant.  Doubtless  in  a  large  number  of  cases  we  should  not  be 
likely  to  cause  renal  irritation  by  the  small  doses  of  chlorate  of  potash 
which  are  usually  given.  Children,  however,  differ  very  much  in  their 
individual  susceptiJDility  to  drugs,  and  we  can  never  tell  beforehand 
whether  or  not  a  child  is  liable  to  be  injured  by  them.  We  know  that 
the  vegetable  salts  of  potash  are  decomposed  in  the  system  and  eliminated 
as  alkaline  carbonates,  thus  causing  no  irritation  in  the  kidney.  Nitrate 
and  chlorate  of  potash,  on  the  other  hand,  which  do  not  part  with  their 
oxygen  in  the  system,  are  excreted  undecomposed  by  the  kidney,  and 
thus  act  as  irritants.  Knowing  that  the  tendency  during  the  Avhole  course 
of  the  disease  is  toAvards  a  renal  hypersemia,  we  should  allow  the  child 
to  have  plenty  of  water  to  drink. 

Unless  the  child  shows  decided  signs  of  suffering  from  a  heightened 
temperature,  antipyretics  in  the  form  of  drugs  by  the  mouth  should  not 
be  used,  as  the  cases  are  rare  where  a  temperature  of  38.8°  to  39.4°  C. 
(102°  to  103°  F.)  for  a  few  days  will  do  harm.  This  is  a  safe  rule  to 
folloAV  in  a  disease  like  scarlet  fever,  in  which,  if  the  child  happens  to  be 
easily  affected  by  fever,  the  unfavorable  symptoms  Avill  appear  at  once 
and  can  be  attended  to.  Our  opinion  is  that  mere  heightening  of  the 
temperature  without  correspondingly  severe  symptoms  causes  much  need- 
less anxiety.  In  typical  mild  cases  of  the  disease,  knowing  that  a  lessen- 
ing of  the  amount  of  the  urine  in  the  prodrominal  stage  as  a  result  of  the 


556  PEDIATRICS. 

higli  temperature  is  a  part  of  the  regular  course  of  the  disense,  the  admin- 
istration of  diuretics  is  not  indicated  beyond  a  plentiful  supply  of  pure 
drinking-water.  Although  the  temperature  may  cause  severe  initial  symp- 
toms, such  as  convulsions,  as  a  rule  it  does  not  have  to  be  directly  treated 
during  the  prodromal  stage.  If,  however,  convulsions  occur  and  continue 
and  the  temperature  is  unusually  high,  such  as  40.5°  or  41.1°  C.  (105° 
or  106°  F.),  and  if  it  remains  at  this  height  Avith  serious  general  symp- 
toms, such  as  delirium,  we  should  endeavor  to  reduce  it  by  sponging  the 
body  with  Avater,  the  temperature  of  which  should  be  Aaried  accordiu'^^  to 
the  special  case.  To  begin  with,  the  temperature  of  the  \vater  should  be 
about  32.2°  C.  (90°  F.).  The  child  is  usually  made  more  comfortable  by 
bathing  if  the  temperature  is  as  high  as  40°  C.  (104°  F.).  The  reduction 
of  temperature  by  water  may  be  accomplished  (1)  by  sponging,  (2)  by  fan- 
ning the  child's  body  wrapped  in  gauze  sprinkled  with  water  of  a  tempera- 
ture of  32.2°  C.  (90°  F.),  and  (3)  by  placing  the  child  direcUy  m  a  tub  of 
Avater  and  at  the  same  time  rubbing  the  body  and  limbs  and  giving  a  stimu- 
lant. The  water  in  the  bath  should  at  first  be  32.2°  C.  (90°  F.),  and 
gradually  reduced  five  or  ten  degrees.  In  extrf  jie  cases  the  cold  pack  by 
means  of  Avet  sheets  can  be  used.  The  child  is  placed  in  sheets  dipped 
in  cold  water  and  then  wrapped  in  a  blanket.  The  sheets  should  be 
removed  in  ten  or  fifteen  minutes,  the  body  and  limbs  rubbed.'  and  a 
stimulant  given. 

We  have  mentioned  before  that  scarlet  fever  is  rare  during  the  first  year 
of  life.  There  are  certain  observations  which  seem  to  show  that  nephri- 
tis is  a  rare  accompaniment  of  scarlet  fever  during  the  first  year.  We 
know  that  milk  is  the  food  which  is  least  irritating  to  the  kidney.  It 
Avould,  therefore,  seem  rational  to  make  milk  the  diet  in  a  disease  which, 
like  scarlet  fever,  points  out  to  us  by  its  pathology  that  we  should  as  far 
as  possible  avoid  uTitating  the  kidney.  It  may  be  merely  a  coincidence, 
but  it  seems  of  some  significance  that  the  first  year  of  life  should  also  be 
the  one  which  is  least  likely  to  present  cases  of  scarlatinal  nephritis. 

When  the  nausea  and  vomiting  are  present,  the  child,  as  a  rule,  feels 
~lbo  sick  to  take  any  nourishment  whatever.  When  the  violence  of  the 
toxic  invasion  has  somewhat  abated,  and  the  diagnosis  of  scarlet  fever 
has  been  made,  orders  should  at  once  be  given  that  the  child  is  to  have 
no  food  but  milk.  The  treatment  of  scarlet  fever  with  a  diet  purely  of 
milk  has  in  my  practice  proved  so  eminently  satisfactory  that  it  has  be- 
come my  routine  treatment  of  the  disease.  During  the  initial  stage  of 
the  disease,  and  until  the  stomach  has  recovered  its  equilibrium,  lime- 
w^ater  should  be  added  to  the  milk  in  the  proportion  of  one  part  to  ten. 
Later  the  alkalinity  of  the  milk  can  be  lessened,  and  after  the  early  days 
of  the  efflorescence  the  milk  may  in  most  cases  be  given  undiluted.  As 
it  is  possible  that  the  nitrogenous  part  of  the  milk  may  be  too  great,  it  is 
well  to  reduce  the  proteids  to  2  per  cent,  and  to  increase  the  sugar  to 
6  or  7  per  cent.     The  administration  of  milk  alone  should  be  continued 


SPECIFIC    INFECTIOUS   DISEASES.  557 

through  the  stages  of  efflorescence  and  desquamation,  and  until  we  are 
justified  in  supposing  that  a  nephritis  will  not  develop  in  the  special  case. 
This  in  general  may  be  estimated  at  from  four  to  five  weeks  from  the 
time  of  the  height  of  the  efflorescence  and  temperature.  Perhaps  in  this 
way  in  a  certain  number  of  cases  a  nephritis  may  be  warded  off,  and  if  it 
develops,  the  patient  is  already  on  a  diet  which  is  best  suited  to  the 
disease. 

During  the  stage  of  efflorescence  there  are  seldom  any  symptoms  which 
require  special  treatment,  in  the  regular  form  of  the  disease,  except  a  con- 
siderable irritation  of  the  skin  which  at  times  arises.  This  can  be  allayed 
by  the  application  either  of  some  simple  ointment  or  of  a  powder  of  oxide 
of  zinc  and  starch  (Prescription  23,  page  .361).  The  use  of  the  ointment 
is  to  be  recommended  not  only  because  it  keeps  the  skin  soft  and  in  good 
condition,  but  also  because  this  application  reduces  the  temperature  some- 
what. Sponging  the  entire  body  with  water  at  a  temperature  of  32.2° 
C.  (90°  F.),  once  or  twice  daily  according  to  the,  comfort  of  the  patient, 
is  to  be  recommended. 

During  the  stage  of  desquamation  the  application  of  a  simple  oint- 
ment to  the  whole  body  is  desirable  both  for  the  purpose  of  softening  the 
disintegrated  epithelium  and  lessening  the  duration  of  this  stage,  and  also 
to  prevent  the  spread  of  the  contagium  by  means  of  the  loosened  scales. 

The  child  should  be  kept  in  bed  until  the  desquamation  has  almost 
entirely  ceased.  This  will  cover  a  period  of  from  four  to  five  weeks. 
By  the  end  of  the  fourth  week,  if  the  desquamation  has  completely  dis- 
appeared, the  diet  can  gradually  be  increased  by  the  addition  of  soup  and 
bread.  It  is  well  to  keep  the  child  in  the  house  for  five  or  six  weeks, 
and  still  longer  if  the  weather  is  cold  or  damp. 

The  urine  should  be  frequently  tested  for  albumin  during  the  first 
three  weeks,  and  afterwards,  when  the  child  is  first  allowed  to  get  up,  after 
each  chaiige  in  diet,  and  after  going  out.  If  any  albumin  is  detected,  the 
child  should  be  immediately  put  back  to  bed  and  on  a  diet  of  milk  until 
the  albumin  has  disappeared.  The  mild  cases  are  the  very  ones  in  which 
a  nephritis  is  liable  to  occur,  and  therefore  we  should  watch  vigilantly  until 
they  are  out  of  danger,  which  is  usually  in  the  fifth  or  sixth  week. 

Serumtherapy. — The  treatment  of  scarlet  fever  by  antistreptococcic 
serum  has  not,  so  far,  been  productive  of  much  good.  In  a  marked  septic 
case  of  the  disease  with  a  profuse  nasal  discharge,  cultures  from  which 
show  the  presence  of  streptococci,  the  antistreptococcic  serum  may  be 
used  as  a  last  resort.  In  McCollom's  experience,  however,  the  serum  has 
not  seemed  to  do  any  good,  although  there  is  no  evidence  that  it  has  done 
any  harm.     It  is,  therefore,  advisable  to  administer  it. 

Until  it  can  be  absolutely  settled  by  experimentation  that  streptococci 
are  the  cause  of  the  disease,  and  until  there  is  a  definite  way  of  differen- 
tiating the  varieties  of  streptococci  the  subject  of  serumtherapy  must 
remain  in  abevance. 


558  PEDIATRICS. 

Eschericli  and  Moser,  in  the  Annakinclerspital  at  Vienna,  since  1902^ 
have  had  remarkable  results  in  the  serum  treatment  of  scarlet  fever.  The 
following  table  gives  the  percentage  of  mortality  of  scarlet  fever  from 
January  1,  1893,  to  July  1,  1904,  in  the  contagious  Avards  of  the  hospital 
just  mentioned.  The  dose  of  the  serum  is  quite  large,  being  200  cc,  but 
no  injurious  results  have  been  noticed  from  this  amount. 

TABLE  61. 
Percentage  of  Mortcihtij  of  Scarlet  Ferer  in  the  Annakinderspitnl  in  Vicxna  from  Jmivari/  1, 


1893,  to  July  1,  1904. 


Year.  Per  Cent. 

1893 25.2 

1894 21. 

1895 20. 

1896 17.6 

1897 11.1 

1898 12.3 


Year  Per  Cent. 

1899 16.4 

1900 12.4 

1901 8.9  Serum. 

1902 6.7 

1903 8.5 

1904  to  Julv,  1904...     7.6 


The  death-rate  previous  to  the  use  of  the  serum  in  the  hospital  seems 
to  have  been  abnormally  high,  much  higher  than  it  is  in  this  country,  so 
far  as  McCollom's  experience  goes.  There  certainly  has  been  a  marked 
diminution  since  the  serum  has  been  used. 

Shaw  says  that  the  mortality  average  in  tliis  hospital  was  14.5  per 
cent,  for  four  years  before  the  serum  treatment  was  adopted,  and  that 
since  its  use  the  average  mortality  rate  for  four  years  was  8  per  cent.  He 
also  says  that  for  the  same  period  in  other  scarlet  fever  hospitals  in  Vienna 
the  mortality  when  the  serum  Avas  not  used  averaged  13.1  per  cent. 

Isolation  and  Disinfection. — The  disease  being  decidedly  infectious 
the  patient  with  the  nurse  should  be  isolated  to  as  great  a  degree  as  cir- 
cumstances will  permit.  An  upper  room  should  preferably  be  chosen. 
It  has  been  observed  in  crowded  parts  of  large  cities  that  scarlet  fever  in 
tenement  houses  is  not  so  likely  to  spread  when  the  first  cases  are  in  the 
top  rooms  of  the  tenements.  In  a  number  of  instances  in  our  practice  we 
^^-Mve  had  one  child  of  a  numerous  family  strictly  isolated  in  the  upper 
story  of  the  house,  and  the  other  children  have  remained  in  the  house 
without  contracting  the  disease. 

The  intensity  of  the  lesions  of  the  skin  and  the  involvement  of  large 
surfaces  indicate  that  the  air  of  the  room  should  be  kept  at  an  ec|uable 
temperature,  in  order  that  the  function  of  the  disabled  skin  should  be 
taxed  as  little  as  possible  and  that  the  internal  organs  should  not  have  too 
great  com.pensatory  work  forced  upon  them.  The  temperature  should 
be  kept  at  about  20°  C.  (68°  F.). 

A  disease  which  renders  confinement  to  the  room  necessary  for  weeks 
demands  a  room  with  good  ventilation  and  plentiful  sunlight.  Therefore, 
a  room  on  the  sunny  side  of  the  house,  having  an  open  fireplace,  should 
be  chosen. 

The  room  should  be  free  from  all  cotton  or  woollen  materials  except 


SPECIFIC    IXFECTIOUS    DISEASES.  559 

such  as  can  be  destroyed  by  fire  at  the  end  of  the  disease.  Tlie  blankets, 
sheets,  towels,  and  clothes  can,  of  course,  be  disinfected,  but  it  will  save 
much  ultimate  trouble  to  remove  the  carpet  and  the  curtains  and  replace 
them  with  pieces  of  old  carpet  and  sheets.  The  pictures,  and,  in  fact, 
everything  worth  preserving,  should  be  removed.  The  room  can  be 
made  sufficiently  cheerful  by  means  of  cheap  colored  prints  and  destruc- 
tible toys  to  amuse  the  child. 

During  the  wliole  course  of  the  disease  the  greatest  care  must  be  taken  to 
disinfect  the  linen  of  both  the  patient  and  the  nurse.  This  should  be  done 
by  soaking  it  for  twenty-four  hours  in  a  five  per  cent,  solution  of  carbolic 
acid,  then  boilhig  it  for  half  an  hour  in  water,  and  finally  washing  it  with 
soft  soap  solution,  20  grammes  (§  ounce)  to  ten  litres  (lOJ  quarts)  Of  water. 

The  dejections  are  to  be  received  in  a  vessel  one-c]uarter  full  of  a  five 
per  cent,  solution  of  carbolic  acid. 

After  the  child  is  entirely  well  it  is  to  be  thoroughly  Avashed  first  in  a 
solution  of  corrosive  sublimate  1  to  10,000.  The  child  is  then  to  be  taken 
to  another  room  to  be  wiped  and  put  into  fresh  clothes,  Avhich  have 
not  been  in  the  scarlet  fever  room.  The  mattress  is  to  be  tied  up  in 
canvas  wet  with  a  corrosive  sublimate  solution  1  to  500,  and  sent  out  of 
the  house  to  be  disinfected,  if  possible  by  steam.  We  usually  advise  the 
family  never  to  have  it  brought  back  again.  In  place  of  the  mattress  it  is 
far  better  to  use  old  blankets,  which,  if  in  sufficient  number,  are  comfort- 
able, and  at  the  end  of  the  sickness  can  be  thoroughly  boiled  and  thus 
disinfected.  The  useless  articles  which  have  been  in  the  room  during  the 
sickness  should  be  burned  in  the  open  fireplace. 

The  room  must  next  be  chsinfected.  This  is  a  very  ditficult  matter  to 
do  absolutely,  but  there  are  several  methods  which  are  far  better  than  the 
usually  recommended  disinfection  by  sulphur  which  has  been  so  generally 
used  for  this  purpose  during  the  past  century.  We  mention  sulphur  as  a 
disinfectant  merely  to  state  that  it  was  proved  by  Koch  as  long  ago  as 
1881  to  be  entirely  unreliable. 

If  there  be  paper  on  the  walls,  it  should  be  scraped  off  and  immediately 
burned.  The  floor  should  then  be  washed  with  a  solution  of  corrosive 
sublimate  1  to  500,  followed  by  soap  water  (a  mop  should  be  used  so  as 
to  avoid  irritation  of  the  hands).  The  ceilings,  the  walls,  all  the  wood- 
work, and  the  furniture  are  to  be  thoroughly  rubbed  with  bread  and  then 
wiped  with  the  corrosive  sublimate  solution  1  to  500.  Esmarch  has  shown 
that  bread  is  the  best  means  of  removing  infectious  material  from  surfaces 
of  this  kind.  The  micro-organisms  adhere  with  great  tenacity  to  the  bread, 
which,  with  any  crumbs  that  break  off  and  fall  to  the  floor,  must  be  care- 
fully collected  and  destroyed  by  Are.  The  room  should  then  be  thor- 
oughly vaporized  for  eight  or  ten  hours  with  formaldehyde  in  the  form  of 
pastilles  or  liquid.  For  ever)-  3500  cubic  feet  of  space  250  grammes  (250 
formalin  pastilles)  of  formaldehyde  should  be  used.  This  can  be  done 
A^ith  a  vaporizing-lamp,  the  room  first  having  been  tightly  sealed. 


560  PEDIATRICS. 

Recent  experiments  show  conclusively  that  formaldehyde  is  a  reason- 
ably good  surface  disinfectant,  but  does  not  penetrate  deeply,  and  is  not  so 
efficient  as  steam.  It  is  good  for  walls  but  not  for  mattresses  or  clothes. 
It  does  not  appreciably  discolor  papers  or  colorings,  and  does  not  affect 
metals. 

The  room  should  then  be  aired  for  several  clays.  If  there  are  other 
children  in  the  house,  it  is  well  to  have  the  whole  room  painted,  including 
the  ceiling  and  the  floor. 

The  physician  should  also  bear  in  mind  that  the  hair,  beard,  and 
clothes  are  possible  means  of  transmitting  the  contagium  from  one  patient 
to  another,  and  that  it  is  his  manifest  duty  to  the  public  to  protect  himself 
and  others  from  the  danger  of  carrying  the  contagion.  It  is  our  custom  to 
wear  a  gown  which  extends  from  the  neck  to  the  floor,  a  cap  with  a  flap 
behind  to  protect  the  hair,  rubber  over-shoes  and  rubber  gloves.  ,  These 
articles  are  put  on  outside  the  sick-room  and  are  discarded  as  one  leaves 
the  room.  They  are  then  left  with  the  nurse  and  disinfected  with  corro- 
sive sublimate  and  are  then  kept  outside  the  sick-room. 

The  following  case  illustrates  the  benign  type  of  scarlet  fever  without 
variation  from  the  regular  type  and  without  complications  : 

A  boy  four  and  one-half  years  old  was  noticed  on  November  6,  when  we  were  vac- 
cinating his  sister,  an  infant,  to  be  quite  sick.  Besides  the  infant  the  boy's  two 
brothers,  one  two  and  a  half  years  old  and  the  other  six,  were  in  the  room  with  him. 
The  mother  supposed  that  the  boy  had  an  attack  of  indigestion.  He  had  been  vomiting 
quite  frequently  and  had  no  appetite.  His  pulse  was  120.  His  temperature  was  38.3° 
C.  (101°  F.).  He  had  no  headache  and  no  sore  throat,  but  he  had  the  appearance 
somewhat  characteristic  of  scarlet  fever  well  marked  on  the  hard  and  the  soft  palate. 
He  was  placed  in  an  upper  room  of  the  house  and  completely  isolated  with  a  trained 
nurse.     The  vomiting  continued  until  evening,  when  it  stopped  and  did  not  return. 

On  November  7  he  was  reported  to  have  had  a  restless  night.  His  throat  was  found 
to  be  very  much  reddened  and  to  feel  a  little  sore.  His  pulse  was  135.  His  tempera- 
ture was  38.3°  C.  (101°  F.).  He  had  had  a  natural  movement  of  the  bowels.  His 
appetite  was  poor. 

All  unnecessary  articles  were  immediately  removed  from  the  room,  and  he  was 
confined  to  his  bed.  He  was  placed  on  a  diet  of  milk  and  given  as  much  water  as  he 
wished  to  drink.     The  efflorescence  of  scarlet  fever  very  soon  appeared  on  his  chest. 

On  November  8  the  efflorescence  had  spread  all  over  his  body.  He  was  reported 
to  have  slept  well  and  to  have  vomited  his  milk  but  once.  His  pulse  was  125,  and  his 
temperature  was  37.7°  C.  (100°  F.).  He  was  sponged  twice  daily  with  water  at  a  tem- 
perature of  32.2°  C.  (90°  F.),  and  as  the  skin  was  somewhat  irritable  the  itching  was 
allayed  with  inunctions  of  vaseline.  The  temperature  of  the  room  was  kept  at  20°  C. 
(68°  F.). 

On  November  9  the  efflorescence  had  spread  to  the  limbs,  and  was  also  present  to 
a  slight  degree  on  the  face.  At  6  a.m.  the  pulse  was  120,  the  temperature  36.6°  C. 
(98°  F.).  At  6  P.M.  the  temperature  was  37.2°  (99°  F.),  and  the  pulse  was  120.  He 
had  a  little  more  appetite,  his  skin  was  less  reddened,  and  his  throat  was  not  so  sore. 

On  November  11  the  efflorescence  began  to  fade,  first  on  the  chest.  On  November 
13  the  temperature  became  normal,  and  desquamation  began,  first  on  the  chest.  On  No- 
vember 25  the  desquamation  had  almost  ceased,  and  the  boy  was  allowed  to  get  up  and 
play  about  the  room  for  an  hour.      On  December  1,  the  desquamation  having  almost 


PLATE   Ylir. 


SPECIFIC   INFECTIOUS   DISEASES.  561 

ceased  for  several  days,  he  began  to  desquamate  freely  again.  On  December  8  the  des- 
quamation ceased.  He  was  disinfected  and  then  sent  down-stairs  among  the  rest  of  the 
children.     He  went  out  of  doors  December  25. 

No  albumin,  was  detected  in  his  urine  during  the  whole  course  of  the  disease.  He 
resumed  his  usual  diet  on  December  10. 

None  of  the  other  children  contracted  the  disease,  although  they  remained  in  the 
house  while  their  brother  was  sick. 

Plate  YIIL,  facing  page  560,  is  a  picture  taken  from  a  boy  ten  years  old  on  the  eighth 
day  from  the  time  of  infection,  the  fourth  day  from  the  beginning  of  the  prodromal 
symptoms,  and  twenty-four  hours  from  the  beginning  of  the  efflorescence.  The  efflo- 
rescence was  in  the  form  of  a  punctate  erythema. 

Variations  l\  Type  of  the  Benign  Form  of  Scarlet  Fever. — In  the 
benign  form  of  scarlet  fever  we  may  have  great  variations  from  the 
typical  manifestations  of  the  disease. 

A  heightened  temperature  in  the  evening  sometmies  continues  for 
over  a  week  after  the  efflorescence  has  faded,  without  the  existence  of  any 
ascertainable  cause :  this  occurrence  should  always  be  looked  upon  with 
suspicion.  After  a  rapid  increase  of  temperature  at  the  beginning  of  the 
disease  there  sometmies  ensues  a  condition  of  complete  apyrexia,  while 
all  the  other  symptoms  continue  to  develop  m  the  usual  manner.  When 
the  temperature  remains  heightened  at  the  end  of  the  period  of  efflores- 
cence and  contmues  into  the  period  of  desquamation,  especially  when 
there  is  no  local  pain  anywhere,  we  should  suspect  that  a  nephritis  may 
be  developing.  When  the  temperature  after  having  become  normal  rises 
again,  we  should  suspect  such  complications  as  otitis  media  and  suppura- 
tion of  the  subcutaneous  tissues  of  the  neck,  or  that  the  heart  is  involved. 

Relapses  may  take  place  in  scarlet  fever,  but  a  true  relapse  is  rare, 
and  a  second  attack,  either  from  auto-infection  or  reinfection  from  an- 
other mdividual  must  be  taken  into  consideration.  In  the  Bagthorpe 
Fever  Hospital,  out  of  two  thousand  cases  fourteen  had  relapses  while 
under  observation.  As  pointed  out  by  McCollom  as  a  result  of  his  studies 
in  a  series  of  one  thousand  cases  at  the  Boston  City  Hospital,  we  may 
meet  Avith  (1)  pseudo-relapses,  where,  after  the  disappearance  of  the  efflo- 
rescence and  at  the  ven^  beginning  of  the  desquamation,  symptoms  of  the 
disease  return  ;  (2)  relapses,  where  after  the  efflorescence  has  disappeared 
and  during  the  stage  of  desquamation  the  symptoms  return  ;  (3)  reinfec- 
tion, after  desquamation  has  ceased  for  a  time.  The  symptoms  of  these 
cases  are  sometimes  more  severe  than  those  m  the  first  attack,  but  in 
most  of  the  reported  cases  of  relapse  in  scarlet  fever  the  first  attack  has 
been  a  mild  one.  Such  cases  occur  usually  in  older  children  rather  than 
in  younger,  and  must  be  sharply  distmguished  from  the  cases  in  wliich 
a  fresh  infection  has  taken  place  and  Avhich  are  characterized  as  a  second 
attack  of  the  disease.  Thomas  reports  a  case  of  scarlet  fever  complicated 
by  varicella,  in  which  on  the  twenty-fifth  day  of  the  scarlet  fever  a  re- 
lapse occurred,  and  on  the  twenty-sixth  day  a  second  attack  of  varicella 

developed. 

36 


562  PEDIATRICS. 

Certain  cases  of  scarlet  fever  have  been  reported  in  which  in  tlie  latter 
part  of  the  disease,  and  after  the  temperature  had  become  normal,  the 
temperature  rose  to  40°  to  41.1°  C.  (104°  to  106°  F.),  when  no  cause 
could  be  discovered  for  the  hyperpyrexia,  and  when  the  patients  recovered 
after  being  promptly  treated  with  cold  baths  to  reduce  the  temperature. 

Scarlet  fever  may  begin  with  such  great  cerebral  excitement  as  to 
lead  us  to  suspect  meningitis,  and  it  may  not  be  possible  to  determine  the 
diagnosis  until  the  efflorescence  has  appeared,  which  may  not  be  until 
even  the  eighth  or  ninth  day. 

The  efflorescence  may  last  only  twenty-four  hours,  or  continue  four- 
teen days.  In  certain  cases  a  recntdcscence  of  the  efflorescence  may  occur. 
In  these  cases,  which  may  be  shomng  a  high  temperature  and  a  brilliant 
efflorescence,  the  efflorescence  after  about  forty-eight  hours  disappears, 
but  the  temperature  remains  elevated,  and  the  efflorescence  again  appears 
twenty-four  hours  later.  We  must  remember  that  we  are  not  to  depend 
upon  the  efflorescence  in  making  our  diagnosis  in  scarlet  fever,  as  it  may 
be  so  evanescent  as  to  be  scarcely  recognizable.  Lemoine,  during  an 
epidemic  in  1895  of  two  hundred  cases,  reports  that  in  thirty-two  of 
these  cases  the  efflorescence  was  limited  to  the  face.  In  some  extremely 
mild  cases  the  efflorescence  may  be  entirely  absent  (scarlatina  sine  erup- 
tione)  or  evanescent,  lasting  perhaps  only  twelve  hours.  The  papillae  of 
the  tongue,  however,  are  enlarged,  there  is  a  slight  efflorescence  on  the 
roof  of  the  mouth,  and  the  diagnosis  should,  therefore,  be  made  from 
the  mouth.  Serious  epidemics  have  been  started  by  this  class  of  cases. 
While  in  ordinary  types  of  the  disease  the  efflorescence  is  not  very  brilliant, 
there  "is  another  set  of  cases  in  which  it  is  very  brilliant  and  is  accompa- 
nied by  a  high  temperature,  which  remains  elevated  for  four  or  five  days 
and  then  often  becomes  normal  as  the  desquamation  begins. 

Convulsions  occurring  at  the  onset  of  the  disease  are  not,  as  a  rule, 
indicative  of  a  fatal  issue,  but  when  they  occur  later  they  are  usually  of 
serious  import. 

The  occurrence  of  scarlet  fever  in  surgical  cases  is  of  no  special  sig- 
nificance beyond  the  apparently  greater  susceptibility  of  patients  with 
open  wounds  to  contract  the  disease.  We  should  bear  in  mind  the  sug- 
gestion of  Osier,  that  in  the  majority  of  these  surgical  cases  thus  far 
recorded  the  efflorescence  has  probably  been  the  red  rash  of  septicaemia, 
and  that  the  reported  cases  have  become  rare  smce  the  gradual  disappear- 
ance of  septicaemia  as  a  complication  of  surgical  operations.  Atkinson 
also  suggests  that  in  many  instances  these  rashes  may  have  been  due  to 
the  quinine  which  was  given  to  the  patient. 

A  variation  may  arise  from  the  ordinary  scarlatinal  inflammation  of 
the  mucous  membrane  of  the  throat  when  the  efflorescence  becomes  more 
severe  than  usual,  resulting  in  a  membranous  exudation  in  the  throat  and 
a  profuse  nasal  discharge  caused  by  streptococci  and  accompanied  by  very 
severe  symptoms,  delirium,  and  a  high  temperature  for  from  twelve  to 


SPECIFIC    I.XFECTIOrS    DISEASES. 


563 


fourteen  daj's,  the  temperature  coming  down  by  lysis.  The  larynx  in  some 
cases  may  also  present  unusual  symptoms,  such  as  aphonia,  and  serious 
symptoms  caused  by  a  concurrent  CEdematous  condition  of  the  glottis  may 
arise  and  produce  even  a  fatal  issue. 

In  the  benign  form  of  scarlet  fever  certain  cases  are  at  times  met  with 
in  which  tlie  high  temperature,  or  the  especial  vulnerability  of  the  child 
to  the  scarlet  fever  contagium,  causes  the  symptoms  to  vary  considerably 
from  the  typical  form  and  to  be  unusually  grave.  An  instance  of  this 
class  of  cases  was  one  Avhich  was  seen  in  consultation  with  Dr.  Robert  P. 
Loring,  at  Xewton  Centre. 

The  child  was  a  girl,  six  years  old.  The  point  of  variation  from  the  typical  cases 
of  scarlet  fever  was  in  this  case  an  unusually  high  temperature.  The  invasion  of  the 
disease  w^as  characterized  by  restlessness  and  sore  throat,  which  was  soon  followed  by 
vomiting  and  delirium.  The  temperature  on  the  first  day  rose  to  41.1°  C.  (106°  F.). 
The  highest  temperature  was  on  the  second  and  third  days,  when  it  reached  41.6°  C. 
(107°  F.).  During  the  first  three  days  the  pulse  could  not  be  counted.  The  high  tem- 
perature continued  until  the  sixth  day  from  the  beginning  of  the  prodromal  symptoms. 
During  the  first  forty-eight  hours  there  was  almost  continuous  vomiting.  This  was 
succeeded  on  the  "third  day  by  frequent  profuse,  and  often  involuntary,  serous  discharges 
from  the  bowels.  These  discharges  continued  until  the  fifth  day.  On  the  fourth  day 
a  slight  erythematous  effloi'escence  appeared  on  the  neck  and  chest,  and  on  the  fifth 
day  it  extended  all  over  the  body  and  was  of- an  intense  character.  On  the  sixth  day 
a  complication  of  pain  in  the  wrists  began,  but  it  disappeared  in  twenty-four  hours 


CHAET  21. 


Days  of  DtSGCL&e 

F 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

c 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORM'L 
TEMP 

98° 
97° 

36° 
1^95° 

:>!  K 

M  i; 

M   E 

Jl   E 

M   E 

M  E 

.M   E 

M   E 

ill  E 

W  F 

>I   E 

.M   E 

Jl  E 

>I   E 

M  J-; 

.M    E 

M    E 

M   E 

.M  E 

.M    E 

M    K 

416° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36  6° 

36.1° 

35.5° 

35.0° 

1 

/ 

/ 

X 

/ 

V 

1 

/ 

1/ 

1 

, 

/ 

1/ 

1    /\ 

A 

A 

V 

/ 

/ 

/ 

/ 

/ 

/ 

^ 

/ 

/ 

.1. 

--- 

-- 

-- 

--- 

-- 

-- 

-- 

-- 

-_. 

-- 

-- 

■-- 

-- 

... 

-- 

V 

/ 

^ 

^ 

^ 

= 

■ 

Toxic  symptoms  and  high  temperature  in  scarlet  fever  treated  hy  baths. 

under  the  administration  of  saUcylic  acid.  At  this  time  also  there  was  marked  swelling 
on  the  left  side  of  the  neck,  which  gradually  disappeared  in  four  or  five  days. 
When    the  fever  was  at  its  height  there  was  considerable  cyanosis,    with  quickened 


564  PEDIATRICS. 

respiration.  The  pulse  at  this  time  was  weak  and  difficult  to  count.  From  time  to 
time  during  the  attack  antifebrin  was  given  for  the  restlessness,  and  bromide  of  soda 
was  occasionally  used.  Tincture  of  digitalis  was  given  when  the  pulse  was  rapid  and 
weak  and  cyanosis  was  present,  but  the  treatment  which  was  most  depended  upon  was 
bathing. 

The  method  of  bathing  for  the  purpose  of  reducing  the  temperature  was  that  of 
placing  the  child  in  a  tub  of  water.  Whenever  the  temperature  reached  40.5°  C. 
(105°  F.)  the  child  was  placed  on  a  pillow  in  the  bath,  and  was  kept  there  until  the 
temperature  was  reduced  three  or  four  degrees.  The  time  required  to  accomplish  this 
was  usually  from  one  to  one  and  a  half  hours.  While  the  child  was  in  the  bath  stimu- 
lants and  milk  were  given  to  it.  The  temperature  of  the  water  was  about  that  of  the 
child,  and  was  gradually  reduced  to  about  32.4°  C.  (90.5°  F.).  During  the  first  four 
days  the  child  was  either  delirious  or  in  a  comatose  condition,  and  when  in  the  bath 
would  pass  its  urine  and  faeces  involuntarily. 

The  high  temperature  continued  until  the  sixth  day  from  the  beginning  of  the 
prodromal  symptoms,  when  it  fell  decidedly,  from  which  time  the  baths  were  omitted, 
and  the  temperature  continued  to  fall  by  lysis  until  it  reached  the  normal  degree  on 
the  sixteenth  day  from  the  invasion  of  the  disease.  After  this  the  child  had  no  un- 
usual symptoms,  and  made  a  rapid  recovery.  There  were  no  complications.  The  des- 
quamation took  the  usual  course. 

Chart  21  shows  the  temperature  in  itiis  case.  The  broken  lines  mark  the  degree 
to  which  the  temperature  was  reduced  by  the  baths. 

Complications  of  Scarlet  Fever. — Most  of  the  complications  which 
arise  in  scarlet  fever  are  due  probably  to  the  action  of  streptococci,  either 
isolated  or  associated  with  other  micro-organisms.  These  micro-organisms 
produce  serious  symptoms,  which  are  often  followed  by  death,  either 
directly  by  giving  rise  to  septicaemic  processes  or  indirectly  by  nephritis. 

It  is  supposed  that  the  infection  which  complicates  scarlet  fever  enters 
the  system  commonly  through  the  pharynx  either  by  direct  absorption  or 
by  inhalation  of  these  organisms. 

Throat. — Symptoms. — In  addition  to  the  milder  forms  of  inflammation 
in  the  throat  which  occur  in  the  course  of  scarlet  fever,  this  simple  in- 
flammation may  be  complicated  by  more  severe  lesions.  In  these  cases 
there  may  be  an  exudation  affecting  the  mucous  membrane  of  the  entire 
buccal  ca^dty  and  throat,  evidently  produced  by  streptococci.  This  com- 
plication adds  greatly  to  the  severity  of  the  scarlet  fever,  and  is  a  com- 
mon source  of  invasion  of  the  ear  and  of  infection  of  the  cervical  glands. 
In  addition  to  lesions  of  this  class  we  meet  at  times  with  a  membra- 
nous condition  of  the  mucous  membrane  of  the  throat,  the  pathological 
lesions  of  which  cannot  be  differentiated  from  those  of  diphtheria.  This 
membranous  condition  is  caused  by  the  action  of  streptococci,  and  the 
diagnosis  between  these  membranes  and  those  which  are  produced  by  the 
Klebs-Loeffler  bacillus  cannot  be  made  except  by  means  of  a  bacteriological 
examination.  These  more  severe  inflammatory^  conditions  of  the  throat 
are  not  common  in  my  experience  outside  of  hospitals,  but  have  been 
observed  a  number  of  times  in  our  scarlet  fever  and  diphtheria  wards  at 
the  Boston  City  Hospital.  In  these  cases  of  streptococcus  invasion  the 
entire  throat  may  be  verj^  much  swollen,  the  tonsils  enlarged,  and  the  naso- 


SPECIFIC    INFECTIOUS   DISEASES.  565 

pharynx  affected  to  such  a  degree  as  almost  to  occlude  the  nares.  It  is 
necessary  to  make  a  bacteriological  examination  of  these  lesions  which 
have  been  called  pseudo-membranes,  if  we  wish  to  determine  in  the  early 
days  of  the  disease  whether  or  not  we  are  dealing  with  a  case  of  diph- 
theria. After  the  first  three  or  four  days  in  most  cases  there  is  usually 
so  marked  a  clinical  difference  between  the  progress  of  the  disease  in 
which  the  Klebs-Loeffler  bacillus  is  present  and  that  in  which  the  exuda- 
tion is  simply  secondary  to  a  streptococcus  invasion,  that  we  are  not  long 
in  doubt  as  to  our  diagnosis,  even  without  the  decisive  proof  by  culture. 
As  a  rule,  when  the  Klebs-Loeffler  bacillus  is  present  the  continued  in- 
crease in  the  severity  of  the  symptoms  and  the  resulting  exhaustion  of 
the  child  show  us  that  we  are  dealing  with  this  micro-organism.  We 
must  not,  however,  be  misled  by  this  general  rule  of  differential  diagnosis, 
for  there  are  many  cases  in  which  it  is  impossible  to  differentiate  between 
a  streptococcus  invasion  and  an  invasion  of  the  Klebs-Loeffler  bacillus 
either  by  the  appearance  of  the  throat  or  by  the  clinical  symptoms.  On 
the  one  hand,  the  streptococcus  invasion  may  be  quite  as  severe  in  its 
symptoms  as  that  of  the  Klebs-Loeffler  bacillus,  while,  on  the  other  hand, 
true  diphtheria  may  occur  where  the  symptoms  are  as  mild  as  any  that 
are  produced  by  the  other  micro-organisms. 

Treatment. — The  treatment  of  the  throat  in  these  severe  secondary 
conditions  is  the  same  as  in  the  treatment  of  the  benign  forms,  except 
that,  if  possible,  it  should  be  carried  out  more  rigorously.  Although 
Seitz  reports  that  he  has  had  excellent  results  from  the  injection  of 
carbolic  acid  into  the  tissues  of  the  tonsils  and  soft  palate,  this  treatment 
requires  still  further  proof  of  its  efficacy  before  it  can  be  recommended. 
As  the  disease  runs  a  comparatively  short  course,  there  is  not  such  a 
need  for  stimulants  as  is  indicated  where  diphtheria  is  present.  In  young 
children  it  is  often  impossible  to  treat  the  throat  locally,  and  we  have  usually 
found  that  our  chief  reliance  in  tiding  over  the  severe  stage  of  the  disease 
is  the  administration  of  sufficient  food,  and  of  stimulants  when  they  are 
indicated  by  the  general  condition  of  the  child.  It  is  to  be  remembered 
that  the  throat  in  scarlet  fever  may  be  attacked  by  the  Klebs-Loeffler 
bacillus  and  the  disease  brought  to  a  fatal  issue  by  a  complicating  diph- 
theria. When  diphtheria  is  present,  the  treatment  should  be  the  same  as 
for  a  primary  case  of  diphtheria. 

In  the  more  severe  forms  of  inflammation  in  the  throat  the  inflamma- 
tory process  may  go  on  to  the  formation  of  an  abscess,  as  in  the  pharynx, 
but  the  most  common  place  is  in  the  tonsil  or  in  its  neighborhood.  These 
abscesses  must  be  carefully  watched  for,  and  when  detected  opened  with 
antiseptic  precautions  as  soon  as  possible.  We  shall  by  this  treatment 
often  shorten  the  course  of  the  disease,  and  thus  save  loss  of  strength 
and  vitality  on  the  part  of  the  patient. 

Cervical  Lymph-Nodes. — Symptoms. — The  cervical  lymph-nodes  of 
the  neck  are  more  or  less  enlarged,  according  to  the  severity  of  the  infec- 


566  PEDIATRICS. 

tion.  This  enlargement  may  in  some  cases  be  so  great  as  to  cause  much 
swelling  and  distortion  of  the  face  and  neck.  The  swelling  extends  at 
times  under  the  chin  from  one  ear  to  the  other  as  a  mass  of  cellulitis. 
The  tissues  of  the  neck  under  these  conditions  may,  as  described  in  speak- 
ing of  the  pathology  of  the  disease,  suppurate,  and  this  condition  even  if 
it  does  not  produce  a  fatal  result  from  gangrene,  may  greatly  prolong  the 
period  of  convalescence. 

Treatment. — While  the  lymph-nodes  are  enlarged  and  tender,  the 
application  of  hot  fomentations  usually  gives  much  relief,  as  an  ice  poultice 
does  also  in  some  cases.  Beyond  this  we  are  not  in  the  liabit  of  making 
any  external  application. 

Bar. — Symptoms. — The  middle  ear  is  so  closely  connected  by  means  of 
the  Eustachian  tubes  with  the  naso-pharynx  that  aural  complications  are 
exceedingly  common  where  naso-pharyngeal  irritation  exists.  The  symp- 
toms which  indicate  that  a  secondary  infection  of  the  ear  is  taking  place 
are  not  always  clear,  as  they  may  differ  much  in  their  manifeslations.  We 
should  therefore  watch  with  the  greatest  solicitude  and  examine  with  the 
greatest  care  the  ear  during  the  course  of  scarlet  fever.  The  symptoms 
may  be  active  and  represented  by  aural  pain  and  great  restlessness.  On 
the  other  hand,  there  may  be  no  apparent  pain,  especially  in  infants  and 
young  children,  who  are  often  unable  to  indicate  the  location  of  the  pains 
by  which  they  are  affected.  In  these  cases  the  symptoms  may  be  merely 
a  somnolent  condition  and  occasional  attacks  of  fretfulness.  ; 

The  younger  the  child,  the  greater  is  its  susceptibility  to  otitis  media. 
Cases  of  scarlet  fever  occurring  in  the  fall  and  winter  are  much  more 
likely  to  develop  middle  ear  complication  than  at  otlier  seasons.  When  it 
does  occur,  both  ears  are  usually  affected  early  in  the  second  week.  If  the 
constitutional  symptoms  of  the  primary  disease  are  severe,  no  new  symp- 
toms show  themselves,  so  that  the  ear  complications  may  be  easily  over- 
looked until  much  damage  has  been  brought  about,  such  as  entire  destruc- 
tion of  the  membrana  tympani  with  loss  of  one  or  more  ossicles.  May  has 
shown  by  statistics  that  of  5613  cases  of  deaf-mutism  572  were  due  to 
scarlet  fever.  The  absence  of  symptoms  pointing  to  the  ear  does  not, 
therefore,  justify  us  in  overlooking  an  otitis  media.  R.outine  examina- 
tions of  the  ears  should  be  made  in  all  cases. 

.  Treatment. — As  soon  as  an  aural  complication  is  detected  the  case 
should  be  referred  to  the  aural  surgeon.  Palliative  measures  to  relieve 
the  congestion  are  often  dangerous.  If  there  is  an  increase  of  inflamma- 
tion in  the  middle  ear,  as  shown  by  marked  swelling  and  congestion, 
especially  of  the  superior  posterior  portion  of  the  membrana  tympani, 
or  by  a  bulging  of  the  membrane,  wdiich  is  seen  to  be  pressed  outward  by 
the  fluid  in  the  tympanum,  paracentesis  with  the  knife  should  be  per- 
formed, always  with  antiseptic  precautions  and  under  good  illumination. 
In  the  early  stages  of  congestion  a  concentric  incision  carried  along  tlie 
superior  posterior  border  of  the  membrana  tympani  through  the  congested 


SPECIFIC   iNFECTIOltS   DISEASES.  567 

region,  and  resulting  in  free  hemorrhage,  will  often  cut  short  an  acute 
process.  A  free  incision  in  the  most  prominent  portion  of  a  bulging 
membrana  tympani,  by  giving  a  vent  to  the  contained  pus,  may  result 
in  speedy  relief  from  both  pain  and  fever,  and  hasten  the  effort  which 
nature  is  making  to  obtain  this  relief.  In  the  acute  congestive  stage,  after 
incision  of  the  membrana  tympani,  drainage- wicks  made  of  dry  absorbent 
cotton  should  be  applied,  and  covered  at  their  outer  end  with  a  pad  of 
absorbent  cotton  filling  the  concha.  These  wicks  should  be  renewed  as 
often  as  both  the  wick  and  the  cotton  pad  become  saturated.  The  dress- 
ing should  be  kept  strictly  aseptic.  After  the  paracentesis  of  the  membrana 
tympani,  if  the  discharge  is  very  thick  and  scanty  the  ear  should  be 
syringed  frequently  with  a  weak,  warm,  2  per  cent,  solution  of  boric  acid 
and  then  carefully  dried  by  means  of  absorbent  cotton  and  cotton  wicks 
applied. 

The  after-treatment  of  the  middle  ear  in  these  cases  in  Avhich  there  is 
no  perforation  of  the  membrana  tympani  should  consist  in  gentle  inflation 
by  means  of  the  air-douche  used  in  accordance  with  the  evidence  afforded 
by  hearing-tests  and  by  the  objective  examinations.  In  cases  in  which 
there  is  perforation  of  the  membrana  tympani  with  continued  suppura- 
tive discharge,  thorough  cleansing  and  constant  drainage  with  cotton-wicks 
should  be  employed. 

Children  are  so  often  rendered  deaf  by  the  morbid  processes  resulting 
from  the  scarlet  fever  contagium  that  it  becomes  a  positive  duty  for  the 
attending  physician  to  watch  the  ear  as  carefully  in  these  cases  as  he 
would  watch  the  heart  in  a  case  of  rheumatic  fever.  In  addition  to  the 
danger  arising  from  a  chronic  disturbance  of  the  tissues  of  the  ear,  the 
rapid  extension  of  secondary  infection  from  the  naso-pharynx  to  the  middle 
ear,  and  thence  through  the  petro-scfuamosal  suture  to  the  cerebral  men- 
inges, is  a  series  of  complications  which  usually  prove  fatal. 

The  following  case  illustrates  the  danger  of  not  treating  promptly  and 
thoroughly  the  compHcation  of  otitis  media  in  cases  of  scarlet  fever. 

A  child  two  and  a  half  years  old  had  been  attacked  with  scarlet  fever  and  later 
with  a  complicating  purulent  otitis.  When  seen  the  child  was  lying  in  a  state  of 
stupor,  apparently  induced  by  pressure  on  the  cerebral  blood-vessels  of  an  unusually 
large  collection  of  pus  in  the  middle  ear  through  the  petro-squamosal  suture.  In  this 
case  rupture  had  taken  place  in  both  tympanic  membranes,  and  the  pus  was  flowing 
in  large  quantities  from  the  external  meatus.  The  perforations  of  the  tympanic  mem- 
branes were,  however,  very  minute,  and  the  cerebral  stupor  was  not  relieved  until  a 
free  opening  was  made  in  each  tympanum  and  the  entire  middle  ear  thoroughly 
syringed  out.  Although  the  symptoms  of  pressure  were  relieved  by  these  procedures 
secondary  infections  of  the  cerebral  meninges  had  already  taken  place,  and  the  boy 
subsequently  died  of  an  acute  purulent  meningitis. 

This  case  warns  us  that  we  should  not  be  misled  by  the  idea  that  a  simple  flow  of 
pus  from  the  auricle  is  necessarily  sufficient  to  provide  a  proper  exit  for  collections  of 
pus  in  the  middle  ear,  and  that,  unless  the  case  is  in  the  hands  of  an  expert  aurist, 
cerebral  pressure  or  purulent  meningitis  is  likely  to  occur  at  any  time.  It  also  illus- 
trates one  of  the  secondary  forms  of  meningitis. 


568  PEDIATRICS. 

Kidney. — Symptoms. — It  is  very  important  to  detect  by  means  of  fre- 
quent analyses  of  the  urine  the  beginning  of  either  the  milder  forms  of  renal 
disturbance  or  of  the  more  severe  forms  of  nephritis,  usually  represented 
by  that  which  is  called  capsular  glomerulo-nephritis.  If  carefully  watched 
for.  the  appearance  of  albumin  will  almost  always  precede  the  clinical  symp- 
toms, and  by  a  still  more  rigid  enforcement  of  the  rules  laid  down  as  prac- 
tically governing  the  treatment,  the  further  development  of  a  nephritis  may 
be  prevented  or  at  least  rendered  much  less  pronounced.  It  is  quite  fre- 
quently the  case  that  a  suspicion  is  first  aroused  of  the  presence  of  a 
nephritis  either  by  vomiting  or  by  oedema  of  the  face,  especially  about  the 
eyes,  and  commonly  occurring  during  the  period  of  desquamation,  from 
the  eighteenth  to  the  twenty-fourth  day.  Under  these  circumstances  the 
urine  will  be  found  to  be  dmiinished  in  quantity  and  to  contain  albumin. 
The  daily  amount  of  the  urine  may  be  reduced  as  low  as  100  c.c.  {3^ 
ounces),  or  even  lower.  The  microscopic  examination  of  the  urine  does 
not  differ  materially  from  that  which  results  from  the  other  forms  of 
nephritis  in  their  early  stages,  but  later  we  may  possibly  find  that  fatty 
casts  are  less  numerous  in  the  nephritis  of  scarlet  fever,  because  there  is 
less  fatty  degeneration  in  the  renal  epithelium.  The  earlier  in  the  course 
of  the  disease  the  symptoms  of  nephritis  appear,  the  more  severe,  as  a 
rule,  will  be  its  type.  The  extent  of  the  albuminuria  is  of  less  conse- 
quence than  the  total  quantity  of  the  urine.  A  rapid  and  extensive 
diminution  of  the  urine  is  ominous,  as  it  indicates  the  accumulation  of 
nitrogenous  waste  in  the  blood  and  the  danger  of  a  resulting  uraemia. 
The  albumin  occurring  early  in  the  disease  is  more  apt  to  be  in  large 
quantities  than  when  it  appears  first  in  the  third  or  fourth  week.  Hsema- 
turia  is  frequently  present  in  this  form  of  nephritis,  but  ordinarily  of 
itself  adds  little  to  the  gravity  of  the  disease.  The  cedema  of  the  face 
may  be  followed  by  a  rapid  involvement  of  the  ankles  and  legs  and  at 
times  may  become  general.  During  the  course  of  a  general  oedema  the 
desquamation  is  apt  to  cease,  returning  on  its  disappearance.  The 
cedema  may  last  for  months  or  may  pass  away  quickly ;  it  may  be  en- 
tirely absent,  but  in  such  cases  the  nephritis  is  almost  invariably  of  a 
light  grade. 

At  times  during  the  presence  of  a  general  cedema  serous  effusions  into 
the  pleura  may  occur.  (Edema  of  the  lungs  and  brain,  although  rather 
rare,  may  also  take  place.  Instead  of  a  slow  development  beginning  with 
oedema  of  the  face  we  may  have  an  acute  attack,  ushered  in  by  fever, 
vomiting,  headache,  oedema,  amblyopia,  coma,  and  convulsions. 

Relapses  may  occur  many  weeks  after  an  attack  of  scarlatinal  ne- 
phritis, and  we  should  watch  the  case  with  the  greatest  care  for  several 
months.  Although  the  nephritis  of  scarlet  fever  may  last  for  months,  it 
has  a  tendency  in  children  ultimately  to  disappear,  on  account  of  their 
wonderful  recuperative  powers.  It  is  also  rare  for  the  renal  disease  fol- 
lowing scarlet  fever  to  become  chronic. 


SPECIFIC   INFECTIOUS   DISEASES.  569 

Retinitis  and  amaurosis  at  times  occur  during  the  progress  of  the  ne- 
phritis in  scarlet  fever.  In  these  cases  of  amaurosis  it  has  been  noticed 
that,  although  the  loss  of  sight  may  be  complete,  almost  always  when 
uraemia  and  amaurosis  are  coincident  there  are  found  no  perceptible 
changes  in  the  retina,  no  congestion  of  the  papillae,  no  increase  of  intra- 
cranial pressure,  and  no  intense  oedema  of  the  brain.  The  sight,  under 
these  circumstances,  may  be  recovered  completely. 

The  alterations  in  the  glomeruli  already  spoken  of  not  only  cause  the 
anuria  and  the  uraemia,  but  also  obstruct  the  renal  arteries,  as  very  nearly 
all  the  renal  blood  has  to  pass  through  the  glomeruli.  We  find  in  cjuite  a 
large  number  of  cases  of  capsular  glomerulo-nephritis  a  rapid  hypertrophy 
of  the  left  ventricle.  This  cardiac  complication  is  not  to  be  confounded 
with  the  endocarditis  which  has  already  been  spoken  of  as  secondary  to  the 
scarlet  fever,  and  which  is  supposed  to  be  caused  by  its  special  poison  or 
by  the  streptococci  which  has  already  been  described  as  being  present  in 
the  disease.  It  is,  in  fact,  not  the  du'ect  result  of  the  scarlet  fever,  but  is 
secondary  to  the  nephritis,  and  is,  in  this  sense,  tertiary  to  the  scarlet  fever. 
We  therefore  do  not  find  this  acute  cardiac  hypertrophy  in  the  earlier 
stages  of  scarlet  fever,  but  when  a  capsular  glomerulo-nephritis  is  once 
established  it  may  take  place  in  so  short  a  period  as  a  week.  This  rapid 
hypertrophy  has  usually  been  observed  in  children  between  the  ages  of 
three  and  six  years,  which  is  of  some  significance  in  explaining  why  this 
hypertrophy  should  take  place  so  easily.  Between  the  ages  of  three  and 
eight  years  a  physiological  hypertrophy  of  the  heart  exists,  possibly  caused 
by  a  continuance  of  the  aortic  narro'\\dng  in  the  neighborhood  of  the  ductus 
arteriosus,  and  the  heart  is  more  readily  affected  by  increased  blood- 
pressure  at  that  age.  This  tendency  to  change  in  the  cardiac  muscles  is 
also  accentuated  by  the  rapid  growth  of  the  organ  at  this  period  of  life. 
Besides  the  cardiac  hypertrophy  we  may,  at  times,  have  an  acute  dilata- 
tion of  the  heart  in  these  cases.  This  is  a  serious  complication,  which 
must  be  guarded  against,  and  when  it  occurs  must  be  recognized  at  once. 
These  cardiac  complications  very  frequently  recover  completely,  as  it 
is  seldom  that  any  extensiA^e  changes  in  the  muscles  of  the  heart  take 
place. 

Although  the  occurrence  of  sugar  in  the  urine  during  the  course  of 
scarlet  fever  is  very  rare,  yet  it  is  well  to  examine  the  urine  for  this  ele- 
ment. By  taking  this  precaution  it  will,  sometimes  be  possible  to  explain 
some  otherwise  obscure  symptoms.  Zinn  reports  a  case  of  glycosuria 
following  scarlet  fever  in  a  boy  four  years  old  who  recovered. 

Treatment. — ^^Vhile  very  little  treatment  beyond  hygienic  measures  is 
needed  for  the  mild  uncomplicated  cases  of  scarlet  fever,  this  can  hardly 
be  said  of  the  cases  that  are  complicated  with  severe  forms  of  nephritis, 
for  in  these  we  must  act  promptly  and  with  great  judgment. 

We  should  be  careful  about  using  diuretics  which  might  irritate  the 
kidney.     Citrate  of  potash  is  one  of  the  safer  diuretics  in  this  complica- 


570  'PEDIATRICS. 

tion.  In  the  lighter  cases  a  lemonade  made  with  bitartrate  of  potash  will 
be  taken  well,  and  will  often  quickly  increase  the  quantity  of  the  urme,  re- 
duce the  oedema,  diminish  the  albumin,  and  cause  a  radical  change  for  the 
better.  This  lemonade  may  be  made  by  using  4  c.c.  (1  drachm)  of  bitar- 
trate of  potash  to  473  c.c.  (1  pint)  of  boiling  water  into  which  a  lemon 
cut  in  thin  slices  has  been  dropped.  This  quantity,  a  little  sweetened,  may 
be  drunk  in  twenty-four  hours  by  a  child  five  years  old. 

In  severe  cases  with  general  oedema  and  threatening  uraemia  cathartics 
are  rather  more  certain  in  their  action  than  diaphoretics  and  diuretics, 
and  are  especially  indicated  when,  as  is  usually  the  case,  constipation  is 
present.  Podophyllin  in  doses  of  0.006  gramme  (yV  grain)  may  be  given 
to  a  child  five  years  old,  and  repeated  a  number  of  times.  It  usually  acts 
quickly.  The  compound  jalap  powder  in  doses  of  0.3  to  0.6  gramme  (5 
to  10  grains)  may  also  be  given  when  a  rapid  and  decided  derivation  by 
the  intestine  is  indicated. 

Having  provided  for  the  proper  movement  of  the  bowels,  if  the  skin  is 
hot  and  dry,  and  ursemic  symptoms,  usually  represented  by  anuria,  som- 
nolence, amblyopia,  and  headache,  are  present,  the  hot  pack,  either  wet 
or  dry,  should  be  resorted  to.  We  prefer  in  these  cases  to  have  the  child 
wrapped  in  a  blanket  and  placed  directly  in  a  tub  containing  water  at  a 
temperature  of  40.5°  to  43.3°  C.  (105°  to  110°  F.).  The  child  should  be 
kept  in  the  water  fifteen  or  twenty  minutes,  and  even  longer  if  necessary, 
and  should  then  be  taken  from  the  wet  blanket,  enveloped  in  hot,  dry 
blankets  and  kept  in  them  until  the  skin  has  become  moist  and  reaction 
has  taken  place.  While  the  child  is  in  the  bath,  milk  can  be  given 
to  it,  and  stimulants  if  they  are  indicated  by  a  weak  or  an  intermittent 
pulse. 

In  addition  to  this  treatment,  hydrochlorate  of  pilocarpine  in  doses  of 
0.003  gramme  (gV  grain)  should  be  given  by  the  mouth  to  a  child  of  two 
years,  and  subcutaneously,  if  desired,  to  a  child  five  years  of  age.  In 
the  cases  of  threatening  uraemia,  convulsions  sometimes  appear  quite 
^_-Suddenly.  Under  these  circumstances  enemata  of  hydrate  of  chloral,  0.3 
to  0.6  gramme  (5  to  10  grains)  dissolved  in  water,  are  of  value  in  con- 
trolling the  nervous  phenomena.  A  combination  of  bromide  of  potash  and 
hydrate  of  chloral  can  also  be  used  as  in  the  following  prescription  : 

Prescription  42. 
Metne.  Apothecary/. 

Gramma. 

B    Chloral  hydrat ; 715  R    Chloral  hydrat gii ; 

Potassii  brom 15[o  Potassii  brom ^iv  ; 

Aq.  destil 90|0  Aq.  destil ^  iii. 

M.  M. 

Sig. — 3.75  c.c.  (1  drachm)  in  30  c.c.  (1  ounce)  of  warm  water:  to  be  given  by  enema, 
and  repeated  in  half  an  hour  if  needed. 

Where  the  ascites  is  extreme,  paracentesis  abdominis  is  often  of  great 
value,  not  only  in  relieving  the  pressure,  but  also  in  increasing  the  action 


SPECIFIC    INFECTIOUS    DISEASES.  571 

of  the  diuretic,  which,  perhaps,  before  was  not  acting  freely.  DigitaHs  is 
a  valuable  remedy  especially  adapted  to  the  treatment  of  the  nephritis  of 
scarlet  fever  and  to  that  of  the  cardiac  changes  which  result  from  it.  By 
the  administration  of  this  drug  the  flow  of  urine  is  increased.  It  is  best 
given  in  the  form  of  a  freshly  prepared  infusion,  in  teaspoonful  doses 
every  four  hours  to  a  child  five  years  old.  Diuretin,  0.3  gramme  (5 
grains),  dissolved  in  water  and  given  two  or  three  times  in  the  twenty- 
four  hours,  has  proved  of  considerable  value  in  our  cases,  and  is  ap- 
parently harmless. 

Joints. — Symptoms. — An  acute  inflammation  of  the  joints,  usually  the 
larger  ones,  is  not  infrequently  met  with  during  the  course  of  scarlet 
fever.  It  is  more  frequent  in  adults  than  in  children,  and  usually  oc- 
curs at  the  end  of  the  first  week  (Marsden).  This  acute  synovitis  may 
be  accompanied  by  endocarditis  and  pericarditis.  The  latter  disease  is, 
however,  rarely  met  with  unless  in  the  later  stages  of  scarlet  fever  in 
cases  in  which  nephritis  has  developed.  As  a  rule,  these  cases  are  not 
of  long. duration,  and  if  effusion  takes  place  in  the  joints  it  is  serous, 
does  not  become  purulent,  and  does  not  give  an  especially  serious 
prognosis. 

In  connection  with  these  cases,  when  uncomplicated  or  when  the  heart 
is  also  affected,  chorea  has  sometimes  arisen  as  a  complication. 

A  more  severe  form  of  synovitis,  apparently  caused  by  secondary 
infection  by  pyogenic  cocci,  may  also  occur  during  the  course  of  scarlet 
fever.  The  effusion  in  the  joints  in  these  cases  may  become  purulent  and 
lead  to  serious  and  permanent  disorganization  of  the  tissues  and  often  to 
death  from  general  septic  infection. 

Besides  these  acute  inflammations  of  the  joints  a  chronic  process  at 
times  arises,  appearing,  as  a  rule,  very  late  in  the  disease  or  subsequent 
to  it  by  many  months.  This  inflammation  is  tubercular  in  character,  and 
affects  with  especial  frequency  the  hip  and  knee.  Although  tubercular,  it 
seems  to  be  a  late  result  of  the  original  toxic  effect  of  the  micro-organ- 
isms of  or  secondarily  connected  with  the  scarlet  fever  contagium. 

In  addition  to  these  more  common  complications  of  scarlet  fever  a 
number  of  secondary  infections  are  at  times  met  with.  Thus,  cases  of 
purpura  following  or  complicating  scarlet  fever  have  been  reported,  and 
are  usually  fatal. 

Bruck  reports  three  cases  of  myositis  of  the  large  muscles  following 
scarlet  fever,  the  symptoms  being  pain,  tenderness,  and  increase  in  the 
size  of  the  muscles. 

The  following  case  represents  one  of  the  milder  forms  of  what  was  probably  cap- 
sular glomerulo-nephritis,  and  the  effect  of  rest  in  the  treatment  of  the  disease. 

A  girl,  five  years  old,  was  attacked  by  scarlet  fever  of  the  benign  form  and  very 
mild  in  its  character.  After  the  usual  prodromal  symptoms  the  efflorescence  appeared 
and  ran  its  course,  and  desquamation  became  established.  At  the  end  of  the  second 
week,  and  while  the  desquamation  was  still  present,  the  child  seemed  so  well  that  it 


572  PEDIATRICS. 

was  allowed  to  be  dressed  and  about  its  room.  It  was  also  allowed  to  have  its  usual 
food,  which  included  a  considerable  amount  of  meat. 

On  January  4  the  child  was  very  irritable  during  the  day  and  passed  her  urine 
involuntarily  in  the  forenoon.  During  the  afternoon  she  was  feverish,  and  passed 
frequently  small  amounts  of  urine.  That  night  she  slept  well,  but  on  awakening  on 
the  morning  of  January  5  she  seemed  dull,  and  was  said  to  be  feverish  and  to  have 
little  appetite. 

On  January  6  the  record  stated  that  she  had  passed  only  90  c.c.  (3  ounces)  of 
urine  in  the  twenty-four  hours.  She  seemed  tired  and  languid,  and  there  was  an 
(Edematous  condition  of  the  eyes  and  upper  part  of  the  face.  She  had  one  normal 
movement  of  the  bowels. 

On  January  7  the  total  amount  of  urine  passed  in  the  twenty-four  hours  was  480 
c.c.  (16  ounces).  She  was  given  infusion  of  digitalis  and  cream  of  tartar  Avater  on 
this  day,  and  placed  on  a  diet  of  milk. 

On  January  8  she  seemed  better,  and  passed  480  c.c  (16  ounces)  of  urine  in  the 
twenty-four  hours.  She  was  then  allowed  to  have  an  increase  in  her  diet,  consisting 
of  various  kinds  of  broth.  An  examination  of  the  urine  by  Professor  E.  S.  Wood  on 
this  day  gave  the  following  result : 

Color Kather  pale. 

Eeaction Acid. 

Uroph^in Diminished. 

Indoxyl Increased. 

Urea Diminished. 

Uric  acid Increased. 

Albumin Considerable  trace. 

Sugar Absent. 

Bile-pigments Absent. 

Specific  gravity 1009. 

Chlorides   Almost  absent. 

Earthy  phosphates  . . .  Diminished. 

Alkaline  phosphates.  .Diminished. 

Sediment Slight  in  amount ;  consisted  chiefly  of  normal  blood-globules,   a 

few  renal  cells,  and  a  few  hyaline,  fibrinous,  blood,  and  epi- 
thelial casts.  The  blood-globules  and  the  casts  were  normal 
in  appearance. 

In  regard  to  this  examination  the  important  features  of  the  urine  were  its  dilu- 
tion, the  great  diminution  in  the  normal  salts,  especially  in  the  chlorides,  the  con- 
siderable trace  of  albumin,  and  the  blood  and  casts.  The  normal  character  of  the 
blood-globules  and  the  comparatively  small  number  of  the  casts  seemed  to  show  that 
only  a  small  portion  of  the  kidney  was  affected.  At  the  time  of  the  great  diminution 
in  the  quantity  of  the  urine  the  tubules  were  probably  nearly  completely  blocked  up. 
The  low  specific  gravity  and  the  great  diminution  of  the  urea  and  chlorides  seemed  to 
indicate  that  it  would  need  but  little  additional  irritation  to  produce  a  marked  nephritis. 
The  condition  appeared  to  be  one  of  a  mild  nephritis. 

The  general  symptoms  presented  by  the  child  and  the  disturbance  of  the  kidney 
shown  by  the  examination  of  the  urine  made  us  advise  that  she  should  be  kept  in  bed 
in  a  warm  room  and  placed  on  a  diet  exclusively  of  milk.  A  warm  bath  Avas  to  be 
given  once  or  twice  daily  until  a  larger  amount  of  urine  was  passed,  and  4  c.c.  (1 
drachm)  of  infusion  of  digitalis  administered  four  times  in  the  twenty -four  hours. 

On  January  9  the  total  amount  of  urine  passed  in  the  twenty-four  hours  was 
reduced  to  90  c.c.  (3  ounces),  and  the  child  was  nauseated  and  vomited  a  number  of 
times  during  the  day. 


SPECIFIC    INFECTIOUS   DISEASES.  573 

On  January  10  she  was  reported  to  have  had  a  very  restless  nigfht  and  to  have  beep 
very  much  excited  on  awakening.  She  had  no  pain  anywhere.  Her  face  continued  to 
be  cedematous.  The  total  amount  of  urine  passed  in  the  twenty-four  hours  was  240  c.c. 
(8  ounces).  She  perspired  slightly,  and  had  one  large,  loose  dejection.  She  so  abso- 
lutely refused  to  take  milk  that  she  was  given  103  c.c.  (3J  ounces)  of  beef-Juice,  which 
was  all  the  nourishment  that  she  took  on  this  day. 

On  January  11  the  face  was  more  oedematous,  and  she  was  languid.  She  had  two 
large,  loose,  offensive  dejections  from  the  bowels,  and  complained  of  a'  burning  sensa- 
tion in  the  rectum  at  the  time  of  the  movements.  The  total  quantity  of  urine  was  300 
c.c.  (10  ounces).  On  this  day  she  was  finally  persuaded  to  take  milk,  and  no  other 
food  was  given  to  her. 

On  January  12  the  child  seemed  brighter  and  the  face  was  not  so  much  swollen. 
The  total  amount  of  urine  in  the  twenty-four  hours  increased  to  540  c.c.  (18  ounces). 
Complete  recovery  took  place  in  three  and  one-half  months  from  the  beginning  of  the 
attack. 

During  the  course  of  her  sickness  various  attempts  were  made  to  increase  her  diet 
more  quickly  and  to  allow  her  to  be  dressed  and  about  the  room,  but  each  time  when 
this  was  done  she  showed  symptoms  which  pointed  towards  the  presence  of  a  renal 
complication,  such  as  a  swelling  of  the  eyes  and  face  and  a  rise  of  temperature,  with 
resulting  nausea  and  loss  of  appetite. 

This  case  shows  how  careful  we  must  be  for  many  weeks  and  even  months  to  con- 
trol the  temperature  of  the  room,  the  amount  of  exercise,  and  the  kind  of  food,  when 
nephritis  has  complicated  a  case  of  scarlet  fever.  It  also  shows  how  entire  recovery 
may  take  place  even  when  the  renal  irritation  is  pronounced  and  unusuallv  prolonged. 

Fig.  182,  on  page  860,  represents  a  case  of  scarlet  fever  complicated 
by  a  probable  capsular  glomerulo-nephritis  and  a  resulting  cardiac  enlarge- 
ment.    The  following  is  a  record  of  the  case  : 

A  boy,  seven  years  old.  entered  the  hospital  on  July  2S.  His  mother  was  living 
and  well,  and  stated  that  his  father  died  of  Bright's  disease.  The  child  was  said  to  have 
been  well  until  five  and  a  half  years  old,  when  he  had  an  attack  of  scarlet  fever,  mild  in 
form  and  not  accompanied  by  any  severe  symptoms.  In  the  latter  part  of  the  attack 
his  temperature  rose  and  he  began  to  have  dyspnoea  and  dropsy.  Since  that  time  he 
had  been  slowly  but  steadily  growing  worse.  He  had  extensive  oedema  of  the  face. 
chest,  arms,  abdomen,  and  legs.  He  was  somewhat  cyanotic,  and  his  breathing  was 
so  much  affected  that  he  was  unable  to  lie  do-^vn,  the  orthopncea  compelling  him  to  be 
supported  in  a  semi-recumbent  position.  There  were  a  slight  pufflness  about  both  eyes 
and  a  yellow  tinge  of  the  conjunctivae.  The  lips  and  tongue  were  cyanotic.  The  ex- 
tremities were  cold  to  the  touch,  and  the  skin  pitted  readily  on  pressure.  The  skin  of 
the  whole  body  was  dry  and  harsh  and  in  certain  portions  covered  ^nth  fine  scales.  On 
the  inner  side  of  the  left  leg  and  on  the  outer  side  of  the  right  leg  were  some  old  scars, 
apparently  resulting  from  a  previous  scarification  performed  for  the  reduction  of  the 
anasarca.  In  addition  to  the  cedematous  condition  of  the  walls  of  the  abdomen,  a 
distinct  fluctuation  was  found  on  palpation.  An  examination  of  the  lungs  showed  that 
there  was  dulness  over  both  bases  behind,  and  over  these  areas  of  dulness,  as  Avell  as 
over  the  whole  front  of  the  chest,  fine  moist  rales  could  be  heard,  indicating  an 
oedematous  condition  of  the  lungs.  The  heart's  impulse  was  most  distinct  in  the  sixth 
interspace  a  little  outside  of  the  mammillan-  line.  The  area  of  cardiac  dulness  extended 
from  the  second  rib  on  the  left  to  2.5  cm.  (1  inch)  to  the  right  of  the  sternum,  in  an 
area  corresponding  to  the  third  interspace  and  fourth  rib.  The  dulness  then  extended 
to  the  left  across  the  sternum  to  a  point  2.5  cm.  (1  inch)  outside  of  the  mammillar}' 
line  and  as  low  as  the  sixth  interspace,  corresponding  to  the  cardiac  impulse.      A  loud 


574  PEDIATRICS. 

isystolic  murmur  could  be  heard  over  the  region  of  the  cardiac  impulse,  and  was  trans- 
mitted so  that  it  could  be  heard  in  every  part  of  the  thorax.  The  total  amount  of 
urine  in  twenty-four  hours  varied  from  900  to  1050  c.c.  (30  to  35  ounces).  An  analysis 
of  the  urine  gave  the  following  results  : 

Color Darker  than  normal. 

Specific  gravity.  .1013. 

Reaction Acid. 

TJrophsein Diminished. 

Indican Increased. 

Chlorides Diminished. 

Albumin |  per  cent. 

Sugar Absent. 

Sediment Very  slight  and  flocculent.  Microscopic  examination  showed  numer- 
ous short  hyaline  and  granular  casts  of  medium  diameter  and 
occasionally  of  small  diameter;  an  excess  of  renal  epithelimn  ;  con- 
siderable abnormal  blood  ;  an  occasional  white  corpuscle ;  one  or 
two  blood-casts,  many  hyaline  and  granular  casts,  with  one  or  more 
renal  cells  adherent ;  occasional  fatty  renal  cells  and  casts  with  a 
few  fat-drops  adherent. 

July  29  he  was  unable  to  lie  down  with  comfort,  on  account  of  dyspnoea  arising 
from  an  accumulation  of  fluid  in  the  abdomen.  The  legs  were  also  very  much  swollen 
and  cedematous.  His  face  was  somewhat  puffy.  The  cyanosis  was  marked  and  the 
child  had  considerable  dyspnoea. 

Paracentesis  of  the  abdomen  was  performed,  and  after  480  c.c.  (16  ounces)  of  clear, 
yellowish  fluid  were  removed  the  cyanosis  and  dyspnoea  were  decidedly  diminished. 

The  treatment  was  absolute  rest,  so  as  not  to  tax  the  muscles  of  the  heart  more 
than  possible,  hot  baths  to  increase  the  action  of  the  skin,  laxatives  to  relieve  the  con- 
gested condition  of  the  kidneys,  and  non-irritating  diuretics,  such  as  citrate  of  potash 
and  digitalis. 

For  the  next  few  days  after  paracentesis  of  the  abdomen  the  child  improved 
greatly,  the  dyspnoea  ceased,  the  urine  became  of  a  better  color  and  increased  in 
amount,  the  cyanosis  grew  less,  and,  although  the  pulse  was  still  small  and  feeble^  the 
child  showed  great  general  improvement.  In  the  course  of  a  month  the  oedema  was 
so  much  reduced  that  the  child  looked  like  a  different  person.  He  was  able  to  lie 
down  with  comfort,  slept  well,  his  appetite  returned,  and  at  one  time  he  could  even 
be  moved  about  the  ward  in  a  wheel-chair.  Some  weeks  later  the  cardiac  symptoms 
returned,  and  he  again  began  to  have  cedema  and  ascites,  cyanosis  and  orthopnoea. 
^ — The  symptoms  were  mostly  those  of  a  crippled  heart. 

On  September  8  the  cedema  increased,  and  the  urine  was  reduced  to  450  c.c.  (15 
ounces).  Diuretin  was  given  in  doses  of  0.6  gramme  (10  grains),  which  increased  the 
flow  of  urine  to  1230  c.c.  (41  ounces).  The  diuretin  given  in  these  doses  once  or  twice 
a  day  for  some  time  continued  to  act  successfully. 

In  October  the  action  of  the  heart  grew  still  weaker,  the  oedema  of  the  lungs  in- 
creased, and,  although  there  had  been  a  general  improvement,  the  child  grew  progres- 
sively weaker  during  November.  Early  in  December  he  was  attacked  with  vomiting, 
had  a  weak  and  rapid  pulse,  gradually  failed  in  strength,  and  on  the  21st  of  December 
died  suddenly.     No  autopsy  \vas  obtained. 

MALIGNANT  FORM   OP   SCARLET  FEVER. 

The  malignant  form  of  scarlet  fever  is  almost  without  exception  fatal, 
and  is  very  rare  in  comparison  with  the  benign  form.  Malignant  scarlet 
fever  appears  to  attack  those  individuals  who  have  a  predisposition  to  be 


SPECIFIC    INFECTIOUS    DISEASES. 


575 


profoundly  affected  by  the  scarlet  fever  contagium.     In  these  cases  we  see 
healthy   children  attacked  with  intense  headache,  high  fever,    delirium, 
sometimes  coma,  and  death  follows  usually  in  two 
or  three  days,  the   course  of  the  disease  being  un-  CHART  22. 

affected  by  treatment.  In  these  cases,  however,  the 
anti-streptococcus  serum  should  be  used,  as  it  has 
not  yet  been  proved  that  it  may  not  arrest  the  dis- 
ease. A  case  of  this  kind  was  seen  in  consultation 
with  Dr.  Emerson,  of  Concord,  and  represents  the 
conditions  which  are  present  in  these  cases  of  malig- 
nant scarlet  fever. 

x\  girl,  eleven  years  old,  was  perfectly  well  and  strong  and 
had  no  other  diseases  up  to  January  10.  In  the  middle  of  the 
day  she  felt  very  ill  and  vomited.  Her  pulse  was  150,  tem- 
perature 40.2°  C.  (104.5°  F.).  The  pharynx  and  tonsils  were 
much  reddened,  but  there  was  no  exudation  or  membrane  to 
be  seen.  An  efflorescence  of  a  scarlatinal  type  appeared  on  the 
chest  in  the  afternoon.  The  vomiting  continued  through  the 
night  and  up  to  the  morning  of  January  11.  The  child  was 
conscious,  but  dull.  The  pulse  was  150,  and  the  temperature 
was  40.5°  C.  (105°  F.).  At  4  p.m.  the  face  became  puffy,  and 
the  efflorescence  was  well  marked  on  the  body  and  extended  to 
the  extremities.  The  child  was  wandering  and  stupid,  and  the 
temperature  rose  to  42.2°  C.  (108°  F.).  The  extremities  be- 
came livid,  and  the  vomiting  began  again.  At  6.30  p.m.  the 
temperature,  after  the  internal  administration  of  various  reme- 
dies, was  found  to  be  41.6°  C.  (107°  F.),  and  at  10  p.m.  41.1° 
C.  (106°  F.),  and  the  pulse  160,  weak  and  difficult  to  count. 
At  6  A.M.  on  the  12th,  within  forty-eight  hours  from  the  appear- 
ance of  the  first  symptoms,  the  child  died 

The  case  was  a  perfectly  hopeless  one  from  the  beginning, 
as  every  method  of  treatment  which  could  be  thought  of  was 
tried  and  proved  absolutely  fruitless.  Tub  bathing  with  water 
at  different  temperatures,  and  finally  sponging  with  ice-water, 
had  no  effect  whatever  on  the  temperature  or  the  general 
symptoms. 

Chart  22  shows  the  temperature  from  the  time  of  the  attack  to  within  a  few  hours 
before  death. 


^aj/s  ofDtsease. 

F 

1 

2 

3 

c 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NOHML 

TEKR 

98° 

97° 
96° 
95° 
150 
140 
130 
120 
110 
100 
90 
80 
70 
60 

M  E 

M  E 

V 

41.6° 

41.1° 

40.5° 

40.0° 

39.4'=' 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36.6° 

36, 1° 

35.5° 

35.0° 

/ 

V 

/ 

/ 

1 

1 

1 

1 

1 

J 

-i- 

V 

\i 

ui 
to 

_J 

rs 

Q. 
1 

== 

== 

Malignant  form  of  scarlet 
fever.    Girl,  11  years  old. 


MEASLES. 

Measles  (rubeola)  is  an  acute  infectious  disease,  supposed  to  be  caused 
by  a  specific  micro-organism,  and  characterized  by  lachrymation,  photo- 
phobia, coryza,  cough,  a  papular  efflorescence,  and  a  slight  desquamation. 

Etiology. — The  micro-organism  which  produces  measles  has  not  yet 
been  determined.  It  is  supposed  to  find  its  vehicle  in  the  tears,  and  in 
the  secretion  of  the  throat  and  nose,  and  possibly  to  exist  in  the  blood. 
Its  tenacity  for  clothing,  thus  continuing  as  a  fresh  source  of  Infection,  is 
mild  in  comparison  with  that  of  scarl-et  fever.  It  is  very  infectious,  and 
in  some  communities  is  at  times  exceeding  fatal.     This  was  the  case  in 


576  PEDIATRICS. 

the  epidemic  of  1873  in  the  Fiji  Islands,  where  it  had  not  occurred  for  a 
long  time  ;  it  spread  rapidly,  and  caused  two  thousand  deaths,  of  which 
sixty-seven  per  cent,  were  in  children  under  five  years  of  age.  The  high 
mortality  in  measles  is,  as  a  rule,  not  caused  by  the  measles  itself,  but  by 
its  complications.  The  epidemics  of  measles  spread  rapidly  and  appear 
to  have  an  element  of  periodicity.  This  has  been  well  exemplified  in 
Boston,  in  the  crowded  districts  at  the  North  End,  where  in  certain  years 
large  numbers  of  children  are  affected,  and  where  in  the  succeeding  years 
the  disease  appears  only  sporadically.  The  disease  occurs  with  about 
the  same  degree  of  frequency  in  the  autumn,  winter  and  spring,  probably 
owing  to  the  close  contact  of  children  in  the  schools.  Measles  can  occur 
three  or  four  times  in  the  same  individual :  this  recurrence  was  one  of  the 
peculiar  features  of  the  epidemic  in  Boston  in  1880.  It  may  attack  young 
infants,  but  is  rare  under  six  months.  After  the  sixth  month,  and  espe- 
cially during  the  first  year,  the  susceptibility  to  the  disease  is  increased, 
and  we  meet  with  the  greatest  number  of  cases  between  the  first  and  the 
fifth  year.  The  susceptDDility  to  measles  appears  to  lessen  as  puberty  is 
approached.  It  is  somewhat  rare  in  adult  life,  although  the  fact  of  its 
attacking  large  numbers  of  adults  was  also  a  peculiarity  of  the  epidemic  of 
1880  in  Boston.  The  comparative  infrequency  of  measles  in  adults  is  due 
not  to  immunity  acquired  by  age,  but  to  the  greater  susceptibility  to  the 
disease  in  childhood  by  which  very  few  pass  through  that  period  without 
an  attack. 

The  contagium  apparently  passes  from  one  individual  to  another  after 
a  very  short  exposure,  and  often  without  any  direct  contact,  as  by  trans- 
mission through  clothing  or  by  the  hands.  It  is  most  infectious  in  the  be- 
ginning of  the  attack,  and  the  infection  may  be  transmitted  three  or  four 
days  before  the  efflorescence  appears  on  the  skin.  There  seems  to  be 
much  less  liability  for  the  transmission  of  the  disease  during  the  stage  of 
desquamation  than  is  the  case  in  some  of  the  other  exanthemata,  such  as 
scarlet  fever  and  variola,  the  means  of  transmission  corresponding  more 
-Jo  that  of  varicella.  Many  authorities  deny  that  the  disease  is  at  all  con- 
tagious after  the  efflorescence  has  entirely  disappeared.  There  is  strong 
evidence  that  a  protected  third  person  cannot  carry  the  disease  unless  the 
contact  between  the  patient  and  the  protected  third  person  has  been  very 
close.  There  is  no  marked  tendency  for  the  contagium  to  cling  to  objects, 
and  the  fomites  after  thorough  exposure  to  air  and  sunlight  are  not  liable 
to  carry  infection.  A  careful  study  of  an  epidemic  of  6000  cases  in  the 
Faroe  Islands,  in  1846,  gave  no  evidence  that  the  disease  was  transmitted 
by  infected  articles  or  by  a  third  person  who  was  himself  immune.  A 
person  suffering  from  an  acute  disease  may  be  temporarily  immune  to 
measles,  or  having  been  exposed  the  period  of  invasion  may  not  develop 
until  convalescence  from  the  acute  disease  is  established.  The  following 
case  illustrates  the  high  degree  of  the  infection  in  the  early  stages  of 
measles. 


SPECIFIC   INFECTIOUS   DISEASES.  577 

A  hoy  who  was  in  a  ward  at  the  Children's  Hospital  was  attacked  with  scarlet 
fever.  He  was  removed  to  the  contagious  ward  and  placed  under  the  care  of  a  special 
nurse,  who  had  orders  to  carry  out  the  most  precise  antiseptic  treatment.  The  direc- 
tions to  the  nurse  were  that  she  should  apply  an  ointment  to  the  child,  rubbing  it  into 
the  skin  thoroughly  from  the  head  to  the  feet  twice  daily.  The  child  was  also  to  be 
bathed  twice  daily  with  a  solution  of  corrosive  sublimate,  1  to  10,000.  The  nurse  was 
cautioned  not  to  allow  her  clothes  to  touch  the  boy's  bed. 

During  the  early  stage  of  this  boy's  desquamation  a  second  boy,  who  occupied  the 
bed  in  the  general  ward  next  to  the  bed  from  which  the  first  boy  had  been  removed, 
was  attacked  with  sore  throat,  vomiting,  and  fever.  We  had  already  paid  our  visit  for 
the  day,  and  the  house  officer,  thinking  the  case  was  probably  one  of  scarlet  fever  con- 
tracted from  having  been  in  such  close  proximity  to  the  bed  from  which  the  first  boy 
was  taken,  had  the  second  boy  removed  to  the  contagious  ward  and  placed  in  the 
same  room  with  the  first  boy.  On  the  following  morning  we  found  that  the  second  boy 
did  not  have  scarlet  fever,  but  had  measles.  We  immediately  had  the  second  boy  re- 
moved to  another  room,  and  he  was  carefully  watched  for  a  week,  supposing  that 
having  passed  the  night  with  the  first  boy,  who  was  in  the  most  infectious  stage  of 
scarlet  fever,  he  might  have  contracted  scarlet  fever.  A  week  passed,  and  he  evidently 
had  escaped  infection  by  the  scarlet  fever  contagium. 

Ten  days  later  the  boy  who  had  scarlet  fever  was  attacked  with  measles,  pre- 
sumably contracted  during  the  night  from  the  boy  who  was  his  room-mate  in  the  early 
stage  of  his  attack  of  measles. 

These  two  cases  apparently  show — first,  that  scarlet  fever,  even  during  its  most 
infectious  stage,  can  in  some  cases  be  prevented  from  spreading  by  thorough  and 
constant  disinfection  ;  secondly,  that  measles  is  highly  contagious  in  its  early  stages. 

Pathological  Anatomy. — Beyond  the  morbid  conditions  which  appear 
on  the  skin  and  on  the  mucous  membrane  of  the  throat,  there  is  no  espe- 
cially characteristic  pathology  of  measles, 

Neumann  has  studied  the  pathology  of  the  skin  in  measles  by  means 
of  specimens  which  were  hardened  in  a  dilute  solution  of  chromic  acid 
and  colored  with  carmine,  haematoxylin,  and  picro-carmine.  The  patho- 
logical changes  were  found  to  be  almost  entirely  confined  to  the  glands 
of  the  skin  and  to  the  blood-vessels.  About  the  walls  of  the  blood- 
vessels, principally  in  the  upper  layers  of  the  cutis,  were  found  collections 
of  round  cells  which  in  crowded  masses  surrounded  the  loops  of  the 
blood-vessels  even  in  the  papillte.  The  blood-vessels  themselves  were 
dilated  and  full  of  blood.  The  coils  of  the  sweat-glands,  as  well  as  the 
excretory  ducts,  were  enveloped  in  accumulations  of  round  cells,  while 
the  neigliboring  tissues  were  filled  with  these  cells.  These  collections  of 
cells  were  always  situated  outside  of  the  walls  of  the  glands.  The  seba- 
ceous glands  presented  like  changes.  The  hair-follicles  showed  rounded 
protuberances  which  corresponded  to  the  points  of  insertion  of  the  erec- 
tores  pilorum,  and  which  were  probably  caused  by  contraction  of  these 
muscles.  In  the  muscles  themselves  there  were  to  be  found,  between 
the  cells  proper  of  the  muscular  tissue,  scattered  round  cells,  which 
showed  the  participation  of  the  muscular  tissue  in  the  inflammatory  pro- 
cess. The  hair-follicles,  in  the  same  manner  as  the  sweat-glands,  were 
seen  to  be   surrounded  in  their  entire   length  by  collections  of  round 

37 


578  PEDIATRICS. 

cells,  which  were  more  numerous  in  the  lower  than  in  the  upper  part 
of  the  skin.  We  therefore  see  that  in  measles  the  pathological  process  in 
the  skin  affects  chiefly  the  blood-vessels  and  glands,  while  the  tissue  proper 
of  the  skin,  as  well  as  of  the  epithelium,  presents  no  marked  changes. 

From  the  fact  that  in  measles  the  pathological  processes  of  the  disease 
are  situated  more  particularly  around  the  blood-vessels  and  cutaneous 
glands,  it  may  be  assumed  that  the  infectious  material  of  the  malady, 
whatever  its  nature,  is  eliminated  from  the  system  through  these  chan- 
nels. 

In  addition  to  the  pathological  lesions  which  occur  in  the  uncompli- 
cated cases  of  measles,  there  is  almost  ahvays  associated  with  the  catar- 
rhal condition  of  the  mucous  membrane  of  the  upper  air-passages  a 
catarrh  of  the  larger  bronchi.  One  of  the  most  common  complications 
of  measles  is  pneumonia ;  this  is  usually  a  broncho-pneumonia,  lobar 
pneumonia  being  comparatively  rare. 

In  some  cases  an  inflammation  of  the  smaller  bronchi  accompanied 
by  pulmonary  collapse  occurs.  The  bronchial  nodes  are  apt  to  be 
swollen  if  the  secondary  infection  is  a  severe  one.  According  to  Osier,  a 
swelling  of  Peyer's  glands  is  net  uncommon,  and  may  be  accompanied 
by  a  hyperaemic  condition  of  the  mucous  membrane  of  the  gastro-enteric 
tract. 

Ear. — Although  a  secondary  infection  of  the  ear  has  been  considered 
rather  distinctive  of  scarlet  fever,  this  complication  has  in  our  experience 
arisen  also  quite  frequently  in  measles.  When  the  ear  is  affected  in 
measles  there  is  a  congestien  of  the  middle  ear.  When  the  onset  of  the 
preliminary  congestion  occurs  in  connection  with  the  inflammation  of  the 
nasal  and  naso-pharyngeal  mucous  membrane,  it  consists  of  a  simple,  gen- 
eral, acute  congestion  of  the  middle  ear,  accompanied  in  the  beginning 
with  serous  exudation,  and  later  with  a  rapid  thickening  of  the  membrana 
tympani  in  connection  with  the  inception  of  the  suppurative  process. 
When,  on  the  other  hand,  the  preliminary  congestion  is  coincident  Avith 
or  follows  the  efflorescence  on  the  face,  the  congestion  is  primarily  in  the 
^upper  portions  of  the  membrana  tympani  as  the  result  of  a  suspension  of 
vasomotor  inhibition.  Under  these  conditions  there  is  a  congestion  of 
the  manubrial  plexus,  of  the  superior  and  posterior  portions  of  the  mem- 
brana tympani,  and  of  the  corresponding  portions  of  the  inner  end  of  the 
external  auditory  canals. 

In  addition  to  this  more  common  condition,  a  general  congestion  of 
the  membrana  tympani  is  found  during  the  stage  of  efflorescence,  and  is 
likely  to  be  more  severe  in  its  type  than  that  which  occurs  during  the 
prodromal  stage  of  measles. 

The  inflammation  of  the  middle  ear  accompanying  measles  is  more 
likely  than  is  scarlet  fever  to  leave  behind  such  trophic  changes  as  thick- 
ening of  the  tympanic  mucous  membrane  with  the  formation  of  ad- 
hesions. 


SPECIFIC   INFECTIOUS   DISEASES.  579 

The  result  of  McCollom's  experience  at  the  South  Department  has  been 
that  the  proportion  of  middle-ear  trouble  and  subsequent  mastoiditis  is 
more  frequent  during  an  attack  of  measles  than  during  an  attack  of  scarlet 
fever.  Downie,  in  501  cases  of  inflammation  of  the  middle-ear  treated  in 
the  Children's  Hospital  in  Glasgow,  gives  the  percentage  of  middle-ear 
involvement  following  measles  as  26.1.  At  the  South  Department  the 
percentage  of  otitis  media  of  greater  or  less  severity  in  1000  cases  of 
measles  was  24.  In  the  mixed  cases  of  scarlet  fever  and  diphtheria  the 
percentage  was  somewhat  higher.  Mastoiditis  occurred  also  more  fre- 
quently in  measles  than  in  scarlet  fever.  The  benefits  of  early  operation 
in  mastoiditis  are  as  great  in  measles  as  in  scarlet  fever. 

During  an  attack  ..pf  measles,  and  subsequent  to  it,  the  tissues  show  an 
especial  vulnerability  to  infection  by  the  tubercle  bacillus.  The  tuber- 
cular infection  may  be  represented  by  the  lesions  of  a  general  miliary 
tuberculosis  or  by  those  of  especial  tissues,  such  as  of  the  cervical  and 
bronchial  nodes,  the  joints,  the  ear,  and,  most  commonly  of  all,  the  lung. 
In  the  latter  instance  the  lesions  are  usually  those  of  a  tubercular  broncho- 
pneumonia. 

Blood. — The  work  done  at  the  South  Department  of  the  Boston  City 
Hospital  by  Tileston  shows  that  during  the  stage  of  incubation  there  is  a 
leucocytosis  which  falls  to  the  normal  early  in  the  prodromal  stage. 
Leucocytosis  does  not  occur  during  the  stage  of  efflorescence  unless  com- 
plications are  present.  The  absence  of  leucocytosis,  however,  during  the 
stage  of  efflorescence  does  not  exclude  a  complication. 

The  polynuclear  neutrophiles  are  increased  during  the  stages  of  incu- 
bation, prodromae,  and  efflorescence.  They  fall  below  normal  at  defer- 
vescence and  reach  normal  in  convalescence.  The  lymphocytes  follow 
the  opposite  course.  At  first  they  are  decreased,  and  then,  after  the 
crisis,  increased. 

The  eosins  are  decreased  or  absent  during  the  efflorescence  and  later 
increased. 

In  doubtful  cases  the  absence  of  leucocytosis  with  decreased  eosins  is 
in  favor  of  measles  as  against  scarlet  fever  and  vice  versa. 

The  blood  becomes  normal  in  all  respects  at  about  the  twelfth  day. 

Incubation. — The  time  of  the  incubation  of  measles  may  vary  very 
much,  and  may  cover  a  period  of  two  or  three  weeks :  the  usual  time, 
however,  is  ten  days. 

Symptoms. — Prodromata. — The  prodromal  stage  varies  in  length,  but, 
reckoning  ten  days  as  the  usual  time  for  the  stage  of  incubation,  the  pro- 
dromal stage  may  be  considered  to  last  from  two  to  three  days,  and  in  some 
cases  four  days.  In  this  stage  we  have  in  typical  cases  of  the  disease  symp- 
toms distinctive  of  measles.  The  invasion  is  characterized  by  severe  ca- 
tarrhal conditions  affecting  the  nose  (coryza),  the  eye  (lachrymation),  and 
the  throat  and  upper  air-passages  (cough).  In  the  first  twenty-four  hours 
the  temperature  rises  to  38°  or  39°  C.  (100.4°  or  102.2°  F.),  and  often  to 


580  PEDIATRICS. 

40°  C.  (104°  F.).  The  height  of  the  temperature  on  the  first  evening  is  a 
fair  indication  as  to  the  severity  of  the  coming  disease.  Thus,  a  tempera- 
ture of  40.5°  C.  (105°  F.)  indicates  a  severe  case.  An  important  point  to 
be  noticed  regarding  the  prodromal  symptoms  is  that  after  the  first  twenty- 
four  hours  there  is  in  a  large  number  of  cases  a  remission  in  the  tempera- 
ture, which  goes  down,  perhaps,  to  37.5°  or  37°  C.  (99.5°  or  98.6°  F.), 
and  remains  down  for  about  twenty-four  hours,  when  it  again  rises.  The 
cough,  coryza,  and  lachrymation,  which  appear  early  in  the  prodromal 
stage,  do  not  abate,  but  rather  increase,  during  this  remission  of  the  tem- 
perature. This  is  an  important  point  to  remember,  as  the  child  who 
seems  quite  sick  and  loses  its  appetite  while  the  temperature  is  high  during 
the  invasion  of  the  disease,  seems  brighter  and  has  ciTeturn  of  appetite  on 
the  second  day  when  the  temperature  is  lower.  Tixis  peculiarity  of  the 
prodromal  stage  is  often  misleading  both  to  the  parents  and  to  the  physi- 
cian, who,  because  the  child  appears  so  much  better,  are  led  to  believe 
that  one  of  the  infectious  diseases  is  not  developing.  In  infants  and  young 
children  the  prodromal  stage  may  begin  with  a  convulsion,  but  this  is  un- 
usual, and  if  it  occurs  it  is  not,  as  a  rule,  particularly  severe,  and  does  not 
necessarily  make  the  prognosis  more  grave.  Headache  in  the  prodromal 
stage  is  cjuite  frequent ;  vomiting  is  rather  rare.  The  tongue  is  usually 
furred,  and  the  mucous  membrane  of  the  throat  towards  the  end  of  the 
second  day,  and  before  the  efflorescence  has  appeared  on  the  skin,  shows 
a  condition  which  is  very  similar  to  that  which  is  about  to  appear  on  the 
skin.  These  lesions,  which  are  especially  pronounced  on  the  soft  and  the 
hard  palate,  are  represented  by  papules  or  macules  of  a  dark-red  and  later 
purplish-red  color,  of  different  sizes,  and  considerably  larger  than  the 
punctate  macules  which  were  described  in  connection  with  the  throat  in 
scarlet  fever.  These  papules  in  certain  cases  are  arranged  crescentically, 
and  may  sometimes  be  found  to  have  coalesced  in  some  parts  of  the  fauces. 
The  mucous  membrane  between  the  lesions  is  comparatively  normal  in 
color,  although  there  may  be  a  slight  hypersemia  of  the  entire  throat.  This 
TTypersemia,  however,  is  not  nearly  so  intense  as  is  seen  in  the  throat  in 
scarlet  fever.  Forchheimer  states  that  the  exanthem  in  measles  begins 
upon  the  soft  palate  from  thirty-six  to  forty-eight  hours  before  the  efflo- 
rescence, in  the  form  of  purplish  or  bluish  papules  arranged  crescentically, 
extends  over  the  mucous  membrane  of  the  cheeks,  and  is  accompanied  by 
a  bluish  color  of  the  tongue.  The  exanthem  is  at  its  maximum  with  the 
beginning  of  the  efflorescence,  and  may  take  as  long  as  three  or  four  days 
to  disappear. 

In  addition  to  the  efflorescence  in  the  throat,  Koplik  has  described  cer- 
tain spots  on  the  mucous  membrane  of  the  cheeks  which  appear  during 
the  prodromal  stage.  He  describes  these  spots  as  minute  bluish-white 
specks  in  the  centre  of  a  reddish  areola.  Widowitch  has  found  them  in 
86.6  per  cent,  of  cases  of  measles,  in  8  per  cent,  of  cases  of  rubella,  and 
in  less  than  1  per  cent,  of  other  cases. 


PLATE   IX. 


Fig.  1. 


Fig.  2. 


/ 


Fig.  3. 


Fig.  4. 


The  Pathogxomoxic  Sigx  of  Measles  (Koplik's  Spots). 

Fig.  1. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  sho"wing  the  isolated 
rose-red  spot,  Vith  the  minute  bluish-white  centre,  on  the  normally  colored  mucous  membrane. 

Fig.  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and  lips ; 
patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter  showing  numerous  pale  bluish- 
white  spots. 

Fig.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles  spots  com- 
pletely coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The  exanthema 
on  the  skin  is  at  this  time  generally  fully  developed. 

Fig.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal  in 
line.    Minute  yellow  points  are  surrounded  by  a  red  area.    Always  discrete. — Med.  yews,  June  3,  1899. 


SPECIFIC  INFECTIOUS   DISEASES.  581 

After  the  remission  of  the  temperature,  on  the  second  day,  the  temper- 
ature again  rises  on  the  third  or  fourth  day. 

Efflorescence. — At  the  end  of  the  third  day  or  at  the  beginnmg  of  the 
fourth  day — that  is,  the  thirteenth  or  fourteenth  day  from  the  time  when 
infection  took  place — an  efflorescence  appears  on  the  skin.  The  efflores- 
cence usually  reaches  its  maximum  in  about  thirty-six  hours,  this  being  a 
more  constant  number  than  the  other  figures ;  that  is,  it  is  about  the  fif- 
teenth day  from  the  date  of  infection.  The  stage  of  incubation  is  rather 
more  constant  than  the  stages  of  prodrome  and  efflorescence,  the  latter 
two  varying  as  to  their  length,  but  together  amounting  to  five  or  six  days. 

When  the  efflorescence  appears  on  the  skin  it  consists  commonly  of 
small  macules  or  papules  on  a  slightly  reddened  base,  which  first  appear 
on  the  face.  As  the  disease  progresses,  these  lesions  extend  to  the  neck 
and  chest,  and  in  the  latter  locality  are,  especially  in  the  beginning,  of  a 
delicate  pink  color,  the  form  of  distribution  in  some  cases  being  crescen- 
tic.  The  efflorescence  then  rapidly  extends  to  the  rest  of  the  body  and  to 
the  extremities.  It  is  usually  more  pronounced  on  the  face,  where  the 
papules  are  apt  to  coalesce,  and  where  an  oedematous  condition  of  the 
tissues,  especially  around  the  eyes  and  nose,  usually  occurs.  The  eyes 
are  swollen  and  partially  closed,  and  the  conjunctivae  are  reddened.  Pho- 
tophobia at  this  time  is  pronounced.  The  efflorescence  may  also  appear 
on  the  scalp.  It  remains  well  marked  for  from  one  to  two  days,  and 
while  it  is  at  its  height  the  temperature  reaches  its  maximum,  and  remains 
high  for  two  or  three  days,  corresponding  to  the  intensity  of  the  efflo- 
rescence. It  then  rapidly  falls,  and  reaches  the  normal  point  in  about 
two  days  more. — that  is,  there  often  appears  to  be  a  distinct  crisis  in  the 
disease.  During  the  period  of  efflorescence,  when  the  temperature  is  still 
raised  and  the  efflorescence  is  at  its  maximum,  it  is  usual  to  have,  in  addi- 
tion to  the  symptoms  of  cough,  coryza,  and  lachrymation,  a  slight  dis- 
turbance of  the  intestines,  represented  by  small,  frequent,  loose  discharges, 
apparently  arising  from  irritation  of  the  rectum  and  descending  colon. 
This  condition  is  seldom  a  serious  one,  and  no  especial  attention  need  be 
paid  to  it  unless  it  should  continue  for  some  days,  or  after  the  maximum 
of  the  temperature  and  efflorescence  has  been  passed  for  a  day  or  two. 

Desquamation. — The  desquamation  is  usually  furfuraceous  in  charac- 
ter,— that  is,  the  epithelium  is  cast  off  in  fine  flakes,  and  is  thus  distin- 
guished from  the  large  lamellar  flakes  occurring  durmg  the  period  of 
desquamation  in  scarlet  fever.  The  desquamation  begins  in  the  order  in 
which  the  efflorescence  came  out. — namely,  first  on  the  face  and  later 
on  the  chest.  The  furfuraceous  character  of  the  desquamation  is  espe- 
cially noticeable  on  the  sides  of  the  nose.  The  disease  usually  runs  its 
entire  course  in  three  weeks. 

Diagnosis. — In  order  to  understand  how  difficult  it  sometimes  is  to  di- 
agnosticate measles,  we  must  recognize  that  it  is  one  of  the  most  variable 
diseases  with  which  we  have  to  deal.     During  epidemics  of  undoubted 


582  PEDIATRICS. 

measles  cases  arise  which  differ  materially  from  the  disease  as  it  appears 
in  its  typical  form,  yet  these  cases,  by  producing  the  typical  form  in  other 
individuals,  prove  that  they  are  all  caused  by  the  same  contagium.  In 
like  manner  certain  epidemics  may  be  characterized  by  irregular  forms  of 
the  disease,  and,  as  true  measles  can  occur  a  number  of  times  in  the 
same  individual,  the  recognition  of  a  sporadic  case  is  often  impossible. 
As  in  other  diseases  of  the  skin,  Ave  should  recognize  measles  not  by  any 
particular  dermal  lesion,  but  by  the  peculiarities  of  the  prodromal  symp- 
toms, the  general  course  and  location  of  the  efflorescence,  the  time  of  the 
maximum  of  the  efflorescence  and  temperature,  and  the  character  of  the 
desquamation.  Thus,  a  prodromal  stage  of  three  or  four  days,  charac- 
terized by  catarrhal  symptoms  of  the  eyes,  nose,  and  upper  air-passages, 
by  the  presence  of  Koplik's  spots  in  a  large  majority  of  cases,  and  a  papular 
efflorescence  appearing  first  on  the  face,  differentiates  the  disease  from 
variola,  varicella,  and  scarlet  fever. 

Prognosis. — The  prognosis  of  measles,  as  a  rule,  is  good,  but  this 
depends  almost  entirely  upon  whether  the  disease  is  free  from  or  accom- 
panied by  complications. 

Treatment. — The  treatment  of  measles  is  essentially  symptomatic. 
There  is  no  known  means  of  producing  immunity  to  the  disease  or  of 
shortening  its  course.  It  is  a  self-limited  disease,  and  the  treatment 
should  be  directed  towards  the  protection  of  the  organs  which  are  most 
likely  to  be  attacked  by  complications.  Bearing  in  mmd  that  the  eye, 
the  nose,  and  the  throat  are  affected  in  the  prodromal  stage,  that  later  the 
skin  is  in  a  very  sensitive  condition,  and  that  the  lung  is  ft-equently  the 
seat  of  some  complication,  we  should  direct  our  treatment  especially  to 
the  care  of  these  organs. 

The  child  should  be  placed  in  a  room  kept  at  an  equable  temperature, 
20°  to  21.1°  C.  (68°  to  70°  F.),  and  well  ventilated.  The  room  should  be 
darkened,  and  the  eyes  should  be  protected  from  light  during  the  whole 
course  of  the  disease.  Unless  this  precaution  is  taken,  the  eyes  are  often 
^.—seriously  affected  for  many  months  after  the  measles  itself  has  disap- 
peared. The  child  should  be  kept  in  bed  until  the  temperature  has  been 
normal  for  a  few  days,  the  efflorescence  has  faded  entirely,  and  the  des- 
quamation has  almost  ceased. 

The  diet  during  the  period  of  the  height  of  the  temperature  should 
be  soup,  milk,  and  bread.  Later,  when  the  temperature  is  normal  and 
desquamation  has  begun,  the  child  can  gradually  have  its  diet  increased, 
until  by  the  third  week  from  the  beginning  of  the  attack  it  is  having  its 
usual  food. 

The  cough,  which  is  very  troublesome  at  times,  does  not,  as  a  rule, 
require  any  special  treatment,  as  it  will  of  itself  in  most  cases  pass  off  in 
a  few  days.  While  it  continues  it  can  be  treated  with  some  simple  mix- 
ture, such  as  camphorated  tincture  of  opium  in  cold  water  in  doses  of 
0.3  to  0.6  c.c.  (5  to  10  minims),  to  allay  the  irritation  in  the  throat. 


SPECIFIC    INFECTIOUS    DISEASES. 


583 


For  the  irritation  of  tlie  nose,  some  simple  refined  oil,  such  as  oleum 
petrolatum  album  dropped  mto  the  nose  with  a  medicine-dropper  is  useful. 
Atomization  should  be  avoided  because  of  the  danger  of  starting  an  acute 
inflammation  of  the  middle  ear  through  the  Eustachian  tubes.  During 
the  invasion  of  the  disease,  however,  these  catarrhal  symptoms  are  exceed- 
ingly difficult  to  control  by  any  treatment  Avhatever. 

As  at  times  there  is  ereat  irritation  of  the  skin  during  the  period  of 
efflorescence,  a  powder  (such  as  Prescription  23,  page  361)  should  be 
applied  thickly  to  the  entire  body  and  limbs.  In  the  place  of  the 
powder  some  simple  ointment,  such  as  petrolatum,  may  prove  to  be 
more   soothing. 

As  a  rule,  the  child  should  be  kept  in  an  equable  temperature  for 
at  least  three  weeks,  and  at  the  end  of  that  time,  if  the  desquamation 
has  ceased,  it  may  be  allowed  to  go  out  of  ito  r  om,  and  out  of  the 
house  a  few  days  later  in  pleasant  weather.  For  several  months,  how- 
ever, it  should  be  carefully  protected  from  sudden  changes  of  atmos- 
phere, as  the  catarrh  of  the  air-passages  is  so  likely  to  leave  them  in 
an  extremely  sensitive  condition  that  a  very  slight  irritation  may  cause 
a  recurrence. 


CHART 

23. 

Days  of  Disease 

F 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

c 

107° 

106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORML 
TEMP 
98° 

97° 

96° 
95° 

M   E 

M  E 

JI  E 

M  E 

M   E 

M  E 

M   E 

M   E 

M  E 

M  E 

4-16° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37  2° 
37  0° 

36  6° 

36.1° 
35.5° 
35  0° 

>    / 

/ 

v' 

V 

1 

J 

/ 

f 

t 

— 

— 

y 

^ 

T>-pica.l  measles. 

Before  the  child  is  allowed  to  leave  its  room  it  should  be  thoroughly 
bathed  from  head  to  foot  in  hot  water.  Although  the  contagium  of 
measles  has  not  the  same  tenacity  for  clothing  as  the  contagia  of  variola 
and  scarlet  fever,  yet  the  room  should  be  thoroughly  aired  and  cleaned 
after  the  child  has  left  it,  and  should  not  be  occupied  by  another  child, 
who  has  not  had  measles,   for  two  weeks.      The  extreme  precautions 


584 


PEDIATRICS. 


taken  in  scarlet  fever  are  not  considered  necessary  for  the  prevention  of 
the  extension  of  measles.  If  the  carpet  had  not  been  removed  when 
the  child  was  put  into  the  room,  it  can  be  taken  from  the  house  and 
thoroughly  cleansed  before  it  is  brought  back.  The  bedclothes  and 
everything  that  can  be  washed  should  be  thoroughly  boiled.  The  room 
should  be  cleansed  and  the  windows  allowed  to  remain  open  for  several 
days,  as  fresh  air  is  one  of  the  best  means  of  eradicating  the  micro-organ- 
isms connected  with  the  exanthemata. 

Chart  23,  page  583,  shows  the  temperature  as  it  usually  occurs  in  the 
typical  and  regular  form  of  measles. 

The  following  case  and  figure  represent  a  typical  case  of  measles  : 


Fig 


A  girl,  six  years  old,  after  an  incubation  of  ten  days,  was  attacked  with  lachryma- 
tion,  coryza,  cough,  and  a  temperature  of  39.4°  C.  (103°  F.).  On  the  second  day 
from  the  beginning  of  the  invasion  the  temperature  fell  to 
37.7°  C.  (100°  F.).  On  the  third  day  it  rose  again,  and  on 
the  fourth  day  the  temperature  rose  to  40°  C.  (104°  F.),  and 
an  efflorescence,  papular  in  character,  appeared  on  the  face 
and  extended  to  the  neck  and  thorax.  The  disease  as  rep- 
resented in  the  picture  is  at  the  height  of  the  stage  of 
efflorescence  on  the  fifth  day  from  the  beginning  of  the  pro- 
dromal symptoms  and  the  fifteenth  from  the  date  of  the  in- 
fection. It  shows  the  swollen  condition  of  the  eyes,  nose, 
and  entire  face.  The  photophobia  was  extreme,  and  there 
was  considerable  lachrymation,  a  continual,  short,  dry  cough, 
and  extensive  coryza.  The  papules  coalesced  on  the  face, 
and  were  of  a  darker  color  than  the  widely  separated  lesions 
on  the  chest. 

Plate  VIII.,  facing  page  560  represents  a  boy,  eight  years 
old,  who  was  at  the  height  of  the  efflorescence  of  an  attack 
of  measles. 

The  different  stages  of  the  typical  lesions  of  measles  are 
represented  on  his  face  and  chest.  The  conjunctivae  are 
reddened,  and  the  eyes,  nose,  and  lips  are  swollen.  The 
efflorescence  in  this  case  ran  a  very  rapid  course,  beginning 

~^Ti  the  face  in  so  intense  a  form  that  the  desquamation  had  already  appeared,  although 
the  efflorescence  on  the  chest  was  in  a  much  earlier  stage  of  development.  The 
papules  and  macules  had  coalesced  on  the  cheeks  and  chin,  while  they  still  appeared 
as  large,  deeply  reddened  lesions  on  the  forehead.  On  the  chin  and  neck  were  areas  of 
normal  skin  appearing  like  white  blotches,  their  boundaries  determined  by  the  clusters 
of  papules.  On  the  side  of  the  nose  there  was  a  slight  desquamation,  which  had  the 
furfuraceous  character  already  described  as  typical  of  measles.  On  the  chest  the 
papules  and  macules  were  much  smaller  in  size,  of  a  much  lighter  color,  and  in  some 
places  had  assumed  a  crescentic  shape. 


Typical  condition  of  the 
face  in  measles.  15  days 
from  infection.  Female,  6 
years  old. 


Variations  in  Type  of  Measles. — Measles  during  epidemics  and  in 
sporadic  cases  varies  much  in  its  type,  and  presents  great  differences  in 
its  prodromal  stage,  in  its  dermal  lesions,  in  its  desquamation,  and  in  its 
entire  course.  Through  a  lack  of  appreciation  of  this  fact  the  diagnosis 
of  other  diseases,  such  as  rubella  and  various  forms   of  erythema,  is 


SPECIFIC  INFECTIOUS  DISEASES.  585 

continually  being  made  when,  in  fact,  the  disease  represents  one  of 
the  more  unusual  forms  of  measles.  If  these  variations  in  measles  were 
better  understood,  we  should  not  fmd  the  disease  rubella  so  often  diag- 
nosticated. 

At  times  the  stage  of  incubation  of  measies  varies  considerably.  It 
may  even  be  extended  from  the  usual  ten  days  to  twenty-one  days. 

Instead  of  the  usual  prodromal  stage,  certain  cases  during  epidemics 
of  undoubted  measles  show  few,  if  any,  prodromal  symptoms. 

In  addition  to  the  usual  catarrhal  symptoms,  in  some  cases  there  are 
vomiting  and  sore  throat.  Again,  instead  of  a  considerable  elevation, 
the  temperature  may  be  scarcely  above  the  normal  degree.  In  addition 
to  the  other  variations  in  the  course  of  the  prodromal  stage  of  measles, 
cases  have  been  noticed  during  epidemics  in  which  the  catarrhal  symp- 
toms were  absent.  Epistaxis  of  a  mild  form,  and  not  apparently  con- 
nected with  the  more  severe  types  of  hemorrhage,  is  sometimes  met 
with.     We  have  seen  it  only  occasionally. 

The  efflorescence,  which  in  the  typical  cases  usually  consists  of  papules, 
or  vesicles  and  papules,  may  vary  so  as  to  simulate  closely  a  common 
erythema,  constituting  the  form  called  Icevis^  or  may  closely  simulate  a 
papular  erythema.  Again,  the  efflorescence  may  in  certain  cases  be 
represented  by  minute  vesicles  or  milia,  characterizing  the  form  called 
miliarius.  Any  of  these  forms  may  be  confluent,  but,  as  a  rule,  only  upon 
the  face. 

There  i^  another  form  of  efflorescence  which  occurs  in  measles,  which 
is  rare,  and  of  a  more  serious  nature  than  the  common  benign  forms 
which  are  met  with  ordinarily.  This  is  called  the  hemorrhagic  or  malignant 
form,  and  is  represented  on  the  skin  by  small  capillary  hemorrhages.  It 
is  often  rapidly  fatal,  and  at  times  appears  to  be  part  of  a  general  hemor- 
rhagic diathesis  represented  by  epistaxis,  hsematuria,  and  hemorrhages 
from  other  localities.  The  temperature  in  these  cases  is  not  typical,  as  it 
does  not  remit  in  the  prodromal  stage,  thus  depriving  us  of  an  important 
means  of  diagnosis  ;  but  a  doubt  as  to  the  nature  of  the  disease  does  not 
last  long,  as  the  other  symptoms  soon  become  prominent.  The  more 
prolonged  the  course  of  this  form  the  better  the  prognosis,  for  if  fatal 
it  is  usually  quickly  so.  It  may  be  complicated  by  a  malignant  broncho- 
pneumonia. 

The  efflorescence,  besides  differing  in  its  form,  may  vary  to  a  great 
degree  in  its  intensity.  Thus,  we  may  have  every  grade  of  papule  or 
macule,  from  the  smallest  to  the  largest,  and  varying  from  a  dark  purplish 
to  a  light  pink  color.  In  like  manner,  although  the  arrangement  of  the 
efflorescence,  especially  on  the  chest,  is  somewhat  crescentic,  yet  during  epi- 
demics of  undoubted  measles  this  crescentic  shape  is  often  absent.  Instead 
of  the  efflorescence  first  appearing  on  the  face  and  then  extending  to  the 
thorax  and  extremities,  we  may  find  in  undoubted  measles  that  it  begins 
first  on  the  chest  or  some  other  part  of  the  body ;   or  the  efflorescence 


586  PEDIATRIC'S. 

may  appear  on  the  face  and  thorax  simultaneously.  We  may  also  find 
that  m  certain  cases  the  efflorescence  appears  first  on  the  abdomen,  or 
on  the  thighs,  and  yet  the  presence  of  other  typical  and  undoubted  cases 
of  measles  in  the  vicinity  or  in  the  same  house  assures  us  that  we  are 
dealing  with  the  same  disease.  The  efflorescence  instead  of  lasting  for  a 
number  of  days  may  be  evanescent  and  may  subside  within  twenty- 
four  hours.  The  entire  absence  of  efflorescence  is  said  to  occur  in 
some  cases,  but  must  be  considered  very  rare,  and  its  possibility  has 
been  doubted. 

The' desquamation  of  measles  is  of  so  light  a  grade  that  it  is  not  sur- 
prising that  in  some  cases  no  desquamation  whatever  is  detected.  Cases 
in  which  desquamation  occurs  without  efflorescence  are  highly  improb- 
able, although  such  have  been  reported. 

During  certain  epidemics  of  undoubted  measles  cases  have  not  infre- 
quently been  noted  in  which  the  post-aural  and  cervical  glands  were 
enlarged. 

There  is  a  form  of  measles,  called  the  recurrent,  which  is  closely  allied 
to  relapsing  fever.  The  main  characteristic  of  this  form  is  the  high  fever. 
The  temperature  will  sometimes  be  raised  for  five  or  six  days,  will  then 
become  normal  for  seven  or  eight  days,  and  will  then  rise  again  with  a 
recurrence  of  the  symptoms.  This  is  a  very  unusual  form,  and  one  which 
needs  merely  to  be  mentioned  here.  It  is  accompanied  by  the  general 
symptoms  connected  with  the  nose,  eye,  and  bronchi  which  are  met  with 
in  the  typical  form  of  measles. 

Relapses  occur  in  measles,  but  they  are  uncommon. 

In  reviewing  the  pictures  which  have  been  given  of  these  variations, 
it  must  be  evident  that,  although  in  the  large  proportion  of  cases  measles 
runs  so  typical  a  course  that  the  diagnosis  is  very  easily  made,  yet  such 
great  variations  in  type  are  always  so  liable  to  occur  that  we  should  be 
extremely  careful  not  to  make  a  diagnosis  of  certain  other  diseases,  such  as 
rubella,  except  under  unusual  circumstances.  This  is  important,  because 
"^e  know  that  during  epidemics  of  well-marked  measles  all  these  great 
variations  as  to  incubation,  prodrome,  efflorescence,  desquamation,  and 
the  entire  course  not  infrequently  arise. 

A  case  which  occurred  in  my  wards  at  the  Boston  City  Hospital  dur- 
ing an  epidemic  of  measles  which  took  place  in  that  institution  illustrates 
how  greatly  the  symptoms  and  appearance  of  the  disease  may  vary. 
The  cases  occurring  in  the  hospital  were  almost  without  exception  of 
the  typical  form,  in  which  no  mistake  could  be  made  as  to  the  diagnosis 
of  measles. 

A  girl  who  was  in  the  hospital,  and  who  was  exposed  to  infection  from  the 
patients  with  measles,  after  feeling  perfectly  well  on  the  previous  day,  was  found  in  the 
morning  to  have  slight  coryza,  coagh,  and  a  papular  efflorescence  not  confluent  even 
on  the  face,  small  in  size,  hght  pink  in  color,  and  not  crescentic.  While  the  efflores- 
cence lasted  the  appetite  was  somewhat  lessened,  and  the  temperature  was  ahout  37.5° 


SPECIFIC    INFECTIOUS    DISEASES. 


587 


C.  (99.5°  F.).  At  the  end  of  twenty-four  hours  the  efflorescence  had  almost  faded, 
and  in  a  few  days  the  general  symptoms  passed  away,  the  patient's  appetite  had  re- 
turned, the  temperature  had  become  normal,  and  she  seemed  perfectly  well. 

If  this  case  had  been  met  with  as  a  sporadic  one,  it  would  have  been  impossible 
to  make  the  diagnosis  of  measles,  and  from  its  mild  nature  it  would  have  been  sup- 
posed to  be  some  slight  form  of  disease,  such  as  rubella. 

We  have  met  with  cases  of  this  type  quite  frequently,  both  during  epi- 
demics and  sporadically ;  their  cause  is  always  obscure,  and  in  them  the 
diagnosis  between  measles,  rubella,  and  papular  erythema  is  often  impos- 
sible. 

The  following  chart  represents  the  temperature  during  the  stage  of 
invasion  and  efflorescence  in  a  typical  case  of  measles,  and  also  the  ac- 
companying mild  congestion  of  the  membranae  tympanorum  which  is  so 
common  in  measles,  and  which  in  this  case  appeared  on  the  eighth  day 
and  closely  followed  the  efflorescence  on  the  face : 


CHAET    24. 


J)aL/s  ofDisease 

F 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

c 

107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NORML 
TEMP 

98° 
97° 

95° 
95° 

M  £ 

11  E 

M   £ 

M   E 

M  K 

M   E 

M   E 

M   E 

M  E 

-M  E 

M  E 

M   E 

M  E 

M   E 

416° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36  6° 

36.1° 

35.5° 

35.0° 

B 

ffl 

or 

93C 

er 

'ce 

/ 

/ 

\ 

\ 

\ 

\ 

/ 

\ 

< 

Co 

7«7< 

?sl 

(or 

> 

/ 

Oj 

-  e^ 

2A2 

/ 

f 

V 

y 

' 

1 

/ 

1 

^ 

1 

=J 

^= 

Measles  with  congestion  of  membranEe  tympanorum  during  stage  of  efflorescence. 

Complications  and  Sequels. — There  are  quite  a  number  of  complica- 
tions and  sequelae  which  may  occur  in  the  course  of  measles.  The  most 
common  of  the  serious  ones  are  pertussis,  pneumonia,  and  tuberculosis. 

Pertussis. — Pertussis  seems  to  have  an  intimate  connection  vdth  mea- 
sles, and  its  occurrence  in  the  course  of  measles  renders  the  prognosis 
more  grave. 

Broncho-Pneumonia. — The  bronchitis  which  is  so  common  an  accom- 
paniment of  measles  sometimes  appears  in  a  more  severe  form,  attacking 
the  smaller  bronchi  as  well  as  those  of  medium  size,  and  may  result  in  a 
broncho-pneumonia,  which  is  much  more  common  as  a  complication  of 


588  PEDIATRICS. 

measles  than  in  lobar  pneumonia.  The  broncho-pneumonia  does  not, 
however,  appear  to  be  more  severe  when  it  arises  as  a  complication  of 
measles  than  when  it  occurs  separately  from  that  disease.  Broncho- 
pneumonia as  a  complication  of  measles  may  occur  very  early  in  the 
course  of  the  disease,  even  during  the  stage  of  invasion ;  but  it  occurs 
most  commonly  towards  the  end  of  the  second  week. 

When,  therefore,  after  the  efflorescence  has  faded  and  the  fever  has 
subsided,  the  temperature  again  rises  without  evidence  of  local  irritation  in 
the  throat,  ear,  or  glands,  we  should  suspect  that  a  broncho-pneumonia 
is  developing.  The  additional  symptoms  of  quickened  respiration  and 
the  movement  of  the  alte  nasi  will  render  still  more  probable  the  suppo- 
sition that  this  complication  is  arising,  even  though  nothing  abnormal  is 
detected  in  the  lung  itself.  The  absence  of  abnormal  physical  signs  in 
the  lung  in  the  early  stage  of  broncho-pneumonia  is  quite  common.  In 
infants  the  temperature  of  tubercular  broncho-pneumonia  does  not  seem 
to  differ  very  much  from  that  of  ordinary  non-tubercular  broncho-pneu- 
monia. The  congestion  of  the  larger  bronchi,  which  appears  to  be  almost 
a  part  of  measles,  may  become  subacute  and  chronic,  instead  of,  as  is 
usually  the  case,  passing  off  soon  after  the  maximum  of  the  temperature 
and  efflorescence. 

Pleuritis  may  occur  in  the  course  of  measles,  but  is  not  so  common 
as  pneumonia. 

Otitis  Media, — When  an  otitis  occurs  as  a  complication  of  measles  it  is 
characterized  by  the  conditions  described  on  page  566.  In  treating  this  com- 
plication the  nose  and  naso-pharynx  should  be  kept  as  clear  as  possible. 
The  same  principles  of  treatment  should  be  applied  as  in  cases  of  otitis 
media  occurring  in  scarlet  fever.     They  have  been  described  on  page  566. 

The  following  case  illustrates  this  aural  complication  occurring  in 
measles : 

A  girl,  one  year  and  seven  months  old,  previously  well,  was  attacked  on  March  6 
with  coryza,  cough,  lachrymation,  a  heightened  temperature,  quickened  respirations, 
and  a  rapid  pulse.  An  efflorescence  of  measles  appeared  on  the  face  on  the  following 
day,  and  the  child  felt  sick,  coughed  continuously,  and  had  a  hoarse  voice.  The  respi- 
rations varied  from  36  to  40,  the  pulse  from  170  to  180.  The  skin  was  hot  and  dry, 
and  the  throat  was  somewhat  reddened.  In  the  afternoon  the  temperature  in  the  axilla 
was  found  to  have  risen  to  40.2°  C.  (104.8°  F.).  She  vomited  and  had  a  convulsion. 
The  nervous  symptoms  passed  off  in  a  few  hours,  free  perspiration  followed,  and  the 
cough  became  somewhat  looser.  At  8  o'clock  in  the  evening  the  temperature  was 
40.1°  C.  (104.4°  F.),  the  respirations  were  quickened,  and  the  pulse  was  rapid. 
Nothing  abnormal  was  found  on  physical  examination  of  the  chest.  During  the  night 
she  was  somewhat  delirious,  and  very  wakeful  and  fretful.  The  temperature  remained 
at  about  40°  C.  (104°  F.),  the  respirations  were  rapid,  and  the  alae  nasi  moved  so  per- 
ceptibly that  it  seemed  as  though  a  pneumonia  must  be  developing.  Frequent  and 
careful  examinations  of  the  lungs,  however,  failed  to  show  anything  abnormal.  She 
continued  to  be  A'ery  restless  during  the  night  and  the  efflorescence  appeared  thickly 
on  the  abdomen  and  legs,  but  very  slightly  on  the  chest.  She  complained  of  pain  in 
the  chest  from  the  continuous  cough,  but  did  not  show  any  symptoms  of  pain  or  dis- 


SPECIFIC   INFECTIOUS   DISEASED  589 

comfort  elsewhere.  Towards  morning  it  was  found  that  an  otitis  of  the  left  ear  had 
developed,  which  in  a  few  hours  caused  perforation  of  the  membrana  tympani.  As 
soon  as  there  was  a  free  flow  of  pus  from  the  ear  the  temperature  fell  to  38.8°  C. 
(101°  F.),  the  respirations  became  quiet  and  normal,  the  alae  nasi  ceased  to  move, 
and  the  child  fell  into  a  quiet  sleep.  On  the  next  day  the  efflorescence  was  pro- 
nounced all  over  the  body,  face,  and  extremities.  From  this  time  the  measles  ran  its 
usual  course,  and  was  followed  by  desquamation  and  complete  recovery. 

The  aural  complication,  however,  proved  to  be  very  intractable,  and  although  it 
was  carefully  treated,  lasted  for  many  months.  The  perforation  of  the  membrana  tym- 
pani did  not  completely  heal  for  over  a  year,  but  the  case  finally  resulted  in  complete 
recovery  without  any  disturbance  of  hearing. 

Eye. — In  addition  to  the  conjunctivitis  which  is-a  common  accompani- 
ment of  measles,  and  vs'hich,  as  a  rule,  requires  no  treatment  beyond  the 
protection  of  the  eyes  from  light,  the  inflammatory  process  may  extend 
to  the  deeper  tissues  of  the  eye  and  cause  other  grave  lesions,  such  as 
hlenorrhagic  conjunctivitis,  keratitis,  and  iritis.  These  complications  should 
be  treated  at  once  by  a  skilled  oculist. 

Tobeitz  has  called  attention  to  the  deleterious  influence  of  measles  in 
rendermg  more  active  any  subacute  or  chronic  affections  of  the  eye  which 
may  have  existed  previous  to  the  disease. 

Thyroid  Gland. — In  a  number  of  cases  an  acute  swelling  of  the  thy- 
roid gland  may  take  place  during  the  course  of  measles.  This  swelling 
of  the  thyroid  gland  may  even  cause  marked  dyspnoea  by  pressure,  but  it 
usually  disappears  in  two  or  three  days.  In  some  cases,  however,  a  for- 
mation of  pus  has  taken  place,  followed  by  destruction  of  a  part  of  the 
gland.  In  intractable  cases  of  this  kind  it  has  been  found  that  the  exter- 
nal apphcation  of  iodine  is  useful. 

Lymph-Nodes. — Enlarged  cervical  lymph-nodes  are  not  so  common 
in  measles  as  in  scarlet  fever,  but  they  riiay  occur,  and  may  even  prove 
serious  from  the  occurrence  of  suppuration. 

Kidneys. — At  times,  at  the  height  of  the  efflorescence,  albumin  may 
appear  in  the  urine ;  but  this  is  frequently  merely  a  transient  congestion 
of  the  kidney,  due  to  the  high  temperature,  and  corresponding  to  the  same 
condition  in  the  period  of  efflorescence  in  scarlet  fever.  Nephritis  may 
complicate  measles,  as  it  does  scarlet  fever,  but  it  is  comparatively  rare. 

Tuberculosis. — The  most  common  sequela  of  measles  is  tuberculosis. 
This  may  occur  either  as  a  general  miliary  tuberculosis  or  as  a  tubercular 
disease  of  any  of  the  organs  or  the  joints.  Tubercular  disease  of  the  joints 
seems  to  show  a  special  predisposition  to  follow  attacks  of  measles.  It  is 
noticeable  that  when  a  patient  with  a  tubercular  joint  has  an  attack  of 
measles  the  process  in  the  joint  is  apt  to  become  temporarily  more  active, 
and  the  prognosis  is  consequently  more  grave.  The  organ  which  in 
measles  is  most  commonly  aff'ected  by  tuberculosis  is  the  lung,  and  the 
most  common  form  of  tuberculosis  of  the  lung  is  a  tubercular  broncho- 
pneumonia. Tuberculosis  of  the  lung  may  often  occur  as  a  sequela  of 
measles  when  pneumonia  has  not  been  present.     In  infants  the  tempera- 


590  PEDIATRICS. 

cure  of  tuberculosis  does  not  seem  to  differ  very  much  from  that  of 
an  ordinary  broncho-pneumonia.  In  regard  to  the  relation  which  exists 
between  measles  and  tuberculosis,  we  should  appreciate  the  danger,  which 
seems  to  be  a  serious  one,  that  the  micro-organism  of  measles  will  render 
active  an  old  and  cjuiescent  tubercular  nidus,  whether  it  be  in  the  bron- 
chial or  the  cervical  glands  or  elsewhere. 

The  following  case  illustrates  the  infection  of  a  patient  with  measles 
by  the  tubercle  bacillus. 

A  girl,  six  years  old,  was  always  well  until  she  had  an  attack  of  measles.  Although 
there  was  no  acute  pulmonary  affection  following  the  attack  of  measles,  she  began  to 
be  affected  with  slight  dyspnoea  and  a  cough  about  one  month  after  the  measles  had 
ended.  A  year  later  these  symptoms  increased,  and  she  had  swelling  of  the  feet  and 
complained  of  general  malaise.  She  also  lost  considerably  in  weight  and  strength. 
On  physical  examination  dulness  was  found  at  the  apices  of  both  lungs,  and  over  the 
dull  areas  coarse  and  fine  moist  rales.  Nothing  abnormal  was  found  in  connection  with 
the  heart  or  kidneys.  The  temperature  varied  from  37.7°  to  38.8°  C.  (100°  to  102°  F.), 
the  respirations  from  30  to  50,  and  the  pulse  from  120  to  130.  An  examination  of  the 
sputum  showed  the  tubercle  bacillus  to  be  present. 

Paralysis. — Another  sequela,  although  a  rare  one,  is  paralysis.  Cases 
thus  complicated  have  shown  mostly  a  paraplegia,  and,  according  to  Osier, 
frequently  can  be  classified  as  post-febrile  polyneuritis,  although  it  is  pos- 
sible that  some  of  them  may  be  due  to  a  rapidly  ascending  myelitis. 

Noma. — A  very  rare  sequela  of  measles  is  the  disease  noma  (cancrum 
oris). 

Among  the  rarer  complications  of  measles  are  empyema,  endocarditis, 
pericarditis,  and  membranous  laryngitis.  Catarrhal  laryngitis  and  tracheitis 
are  not  infrequent  accompaniments  of  the  acute  stage  of  measles.  (Edema 
of  the  glottis  is  rare,  but  has  been  known  to  occur. 

The  irritation  of  the  intestine,  occurring  commonly  during  the  height 
of  the  efflorescence  and  temperature,  sometimes  becomes  much  more 
severe  from  the  development  of  colitis  as  a  complication. 

RUBELLA. 

Rotheln ;  German  Measles. — It  is  now  almost  universally  believed 
that  there  is,  in  addition  to  variola,  varicella,  scarlet  fever,  and  measles, 
a  highly  infectious  acute  disease  accompanied  by  an  efflorescence  on  the  skin 
which  is  distinct  from  these  other  members  of  the  group  of  exanthemata. 
While  Ave  must  recognize  the  propriety  of  mentioning  the  existence  of 
this  disease  when  speaking  of  this  class  of  affections,  we  must  also  ac- 
knowledge that  it  is  the  weight  of  opinion,  and  not  of  proof,  w^hich  has 
characterized  rubella  as  a  disease  sui  generis.  The  cause,  the  sympto- 
matology, and  the  resulting  diagnosis  of  rubella  must  be  left  for  future 
investigation,  until  the  special  micro-organism  which  produces  it  and 
that  which  produces   measles   can  be  separated  bacteriologically.     The 


SPECIFIC   INFECTIOUS   DISEASES.  591 

difficulty  which  arises  in  differentiating  rubella  from  the  other  diseases 
of  this  class  is  chiefly  in  distinguishing  it  from  measles.  We  cannot 
describe  a  typical  case  of  rubella  in  such  a  way  as  to  enable  us  to  diag- 
nosticate the  disease  in  a  sporadic  case.  On  the  other  hand,  this  can  be 
done  so  readily  with  the  other  exanthemata  that  we  can  at  once  diagnos- 
ticate a  sporadic  case. 

Symptoms. — Rubella  is  described  in  many  ways  by  observers  in  differ- 
ent localities,  but  is  usually  spoken  of  as  essentially  a  highly  infectious 
disease,  v/ith  an  incubation  of  two  or  three  weeks,  with  slight  or  no  pro- 
dromata,  and  with  a  slightly  raised  temperature,  accompanied  by  mild 
catarrhal  symptoms,  and  often  by  sore  throat  and  swelling  of  the  cervical 
and  post-auricular  glands. 

Efflorescence. — The  efflorescence  is  commonly  described  as  papular  or 
macular  in  form,  of  light  grade,  often  evanescent,  and  seldom  showing  any 
desquamation.  Forchheimer  has  described  what  he  designates  as  an  ex- 
anthem  appearing  on  the  mucous  membrane  of  the  fauces  at  the  same  time 
that  the  efflorescence  appears  on  the  skin.  This  enanthem  has  the  same 
characteristics  as  that  on  the  skin,  excepting  so  far  as  it  is  modified  by 
the  difference  in  locality.  Forchheimer  believes  that  tliis  enanthem  is 
characteristic  of  German  measles,  and  states  that  it  is  very  short-lived, 
fades  away  within  the  first  twenty-four  hours,  and  is  localized  upon  the 
velum  of  the  palate  and  on  the  uvula,  but  rarely  invades  the  hard  palate 
or  any  other  part  of  the  mouth.  The  efflorescence  consists  of  macular, 
distinctly  pink-red  spots  resembling  the  roseola  of  typhoid  fever,  arranged 
irregularly,  not  crescentically,  about  the  size  of  large  pin-heads,  very  little 
elevated  above  the  level  of  the  mucous  membrane,  and  with  very  little 
infiltration.  These  spots  come  out  in  their  largest  circumference,  do  not 
increase  in  size,  and  during  their  involution  sometimes  leave  yellowish- 
brown  spots  or  streaks.  Koplik's  spots,  considered  by  him  to  be  charac- 
teristic of  measles,  are  said  never  to  be  present  in  German  measles, 
but  have  been  found  by  Widowitch  ten  times  in  a  series  of  one  hundred 
and  thirty-five  cases  of  rubella. 

Complications  or  sequeke  following  rubella  are  said  to  be  uncommon. 
If  a  careful  study  is  made  of  the  variations  which  occur  commonly 
during  epidemics  of  undoubted  measles,  it  will  be  seen  tliat  this  descrip- 
tion of  rubella  is  one  which  may  be  applied  to  many  mild  cases  of 
measles.  As,  however,  epidemics  arise  in  which  these  characteristically 
mild  symptoms  occur  in  many  cases,  and  these  cases  may  give  rise  to 
similar  cases,  it  is  probable  that  in  the  future  a  micro-organism  distinctive 
of  rubella  will  be  found. 

Diagnosis. — Bearing  in  mind  the  facts  which  have  been  mentioned,  we 
can  merely  say  regarding  rubella  that  its  diagnosis  can  seldom  be  made  in 
a  sporadic  case. 

Prognosis. — The  prognosis  is  good. 

Treatment. — The  treatment  is  that  of  a  mild  case  of  measles. 


592  PEDIATRICS. 

VARIOLA, 

Etiology. — Variola  (small-pox)  is  one  of  the  most  virulent  of  the 
infectious  diseases  with  which  we  haA'e  to  deal,  and  is  particularly  fatal 
among  infants  and  young  children.  The  organism  which  causes  this 
disease  is  a  parasite  and  has  been  described  by  Councilman,  Magrath,  and 
Brinckerhoff  under  the  name  of  cytoryctes  variolae.  Virus  from  variola 
inoculated  into  the  skin  of  man  never  produces  true  variola,  but  only 
A^ariola  inoculata.  True  variola  is  transmitted  through  the  air.  Brincker- 
hoff found  that  monkeys  could  be  given  variola  inoculata  and  vaccinia, 
but  that  they  never  contracted  true  variola  when  made  to  live  with  small- 
pox patients  and  when  covered  with  infected  blankets.  He  concludes 
that  variola  has  two  forms  of  contagium, — one  air-born,  producing  true 
small-pox  ;  the  other  requiring  inoculation  and  producing  variola  inocu- 
lata. This  latter  form  is  thus  analogous  to  vaccinia,  which  also  is  not  air- 
born,  but  requires  inoculation. 

Of  interest  is  the  fact  that  the  variola  parasite  presents  two  life-cycles, 
whereas  vaccinia  presents  only  one,  thus  suggesting  that  two  life-cycles 
may  explain  the  air-born  contagium.  Variola  is  characterized  by  severe 
constitutional  symptoms,  accompanied  by  a  progressive  efflorescence  from 
macules  and  papules  to  vesicles  and  pustules,  followed  by  the  formation 
of  crusts,  these  lesions  having  a  tendency  to  result  in  cicatrices.  Variola, 
in  contradistinction  to  varicella,  scarlet  fever,  and  measles,  is  an  ex- 
tremely rare  disease  among  infants  and  young  children  who  have  been 
vaccinated. 

Although  there  are  no  characteristics  of  variola  which  are  distinctive 
in  children  from  those  of  the  disease  occurring  in  adults,  it  is  important 
to  recognize  its  chief  features  for  the  purpose  of  ctifferential  diagnosis. 
It  is  possible  for  the  foetus  to  contract  the  disease  in  utero.  This,  how- 
ever, is  rare,  and  it  is  well  known  that  infants  whose  mothers  are 
affected  with  variola  can,  even  when  born  in  small-pox  hospitals,  be  pro- 
tected from  the  disease  if  vaccinated  immediately.  The  contagium  is 
supposed  to  exist  in  the  secretions  and  excretions,  and  to  emanate  from 
the  exhalations  of  the  lungs  and  from  the  skin.  It  is  in  all  probability 
transmitted  principally  by  means  of  particles  of  the  crusts.  It  has  a 
wonderful  tenacity  for  clothing  or  any  like  means  of  conveyance.  It 
has  been  proved  that  the  contagium  is  active  before  the  efflorescence 
occurs,  though  not  so  much  so  as  later.  It  has  also  been  fairly  well 
proved  that  its  activity  ceases  when  all  the  crusts  have  fallen  off  and 
when  the  entire  skin  has  become  smooth.  The  most  virulent  form  of 
the  disease  can  be  contracted  from  a  mild  form,  such  as  varioloid. 

Pathological  Anatomy. — The  pathological  conditions  found  in  variola 
are  chiefly  those  of  the  skin  and  the  mucous  membranes.  The  lesion 
begins  as  a  round,  somewhat  raised  macule,  which  develops  into  a  hard 
papule,  and  later  a  small  vesicle  anses  on  its  summit.     This  vesicle  enlarges 


SPECIFIC   INFECTIOUS  DISEASES.  593 

very  rapidly  and  changes  to  a  tensely  filled  pustule  with  a  central  depres- 
sion. The  size  of  this  pustule  corresponds  to  that  of  the  original  macule. 
Microscopically  the  macule  consists  of  a  circumscribed  spot  of  hypersemia 
in  the  capillary  layer  of  the  skin.  The  papule  is  formed,  according  to 
Weigert,  by  a  sharply  defined  necrobiotic  degeneration  of  the  under 
layers  of  the  rete  mucosum,  by  which  process  the  nuclei  of  the  epithelial 
cells  are  destroyed.  By  the  transudation  of  fluid  into  these  areas  the 
cells  are  pushed  apart  and  the  epithelial  layer  is  lifted  up  as  a  Avhole, 
covering  the  area  affected,  and  forms  a  vesicle,  "the  inner  part  of  which  is 
composed  of  a  mesh-work  filled  with  lymph.  In  the  vicinity  of  the  ne- 
crobiotic focus  an  inflammation  is  set  up,  causing  an  increased  growth  of 
the  cells  of  the  rete  which  surround  the  walls  in  the  focus  on  all  sides. 
The  developed  pustule  extends  through  the  whole  thickness  of  the  cutis 
to  the  subcutaneous  tissue.  A  net-work  inside  the  pustule,  which  is  most 
tense  in  the  central  part,  connects  the  roof  and  the  floor  of  the  pustule, 
and,  in  conjunction  with  the  above-mentioned  growth  pf  the  cells  of  the 
rete  around  the  focus,  causes  the  central  depression.  If  the  vesicle  is 
pricked,  only  a  part  of  the  lymph  flows  out  of  the  mesh-work  within. 
The  lymph  is  clear,  and  contains  some  white  and  red  blood-corpuscles, 
streptococci  and  staphylococci,  fibrin-flocculi,  and  molecular  granules.  The 
contents  of  the  pustule  are  purulent,  and  those  in  the  hemorrhagic  form 
contain  blood.  Clumps  of  bacteria  with  analogous  localized  degeneration 
and  its  associated  changes  are  found  in  the  neighborhood  of  the  pustules, 
also  in  the  parenchyma  of  the  internal  organs  and  lymph-glands,  as  well 
as  in  the  skin.  These  secondary  infections  are  largely  responsible  for  the 
stage  of  pustules  and  for  the  toxic  symptoms.  The  severe  hemorrhagic 
and  malignant  forms  are  probably  dependent  more  upon  the  activity  of 
the  secondary  streptococcus  and  staphylococcus  infections  than  upon  the 
primary  infecting  agent.  When  the  variola  has  reached  its  height  the  cen- 
tral depression  in  the  pustule  disappears,  because  the  increased  tension  in 
the  contents  tears  away  the  mesh-work.  The  vesiculation  begins  in  the 
upper  central  part  and  spreads  downward  towards  the  periphery.  The 
pustule  then  collapses  and  changes  to  a  crust,  which  after  a  certain 
number  of  days  falls  off,  leaving  a  more  or  less  deep  scar  covered  with 
young  epithelium.  If  the  suppuration  extends  into  this  layer,  scarring 
invariably  results ;  it  does  not  necessarily  follow  if  the  suppuration  is 
confined  to  the  upper  layer.  A  distinct  difference  in  the  anatomy  of  a 
pustule  of  variola  vera  and  one  of  varioloid  does  not  exist. 

On  the  mucous  membranes  of  the  mouth,  nose,  conjunctivae,  bronchi, 
CESophagus,  rectum,  sometimes  the  vagina,  and  also  on  the  tonsils  and 
the  tongue,  the  same  pustular  efflorescence  may  be  found,  and  is  either 
superficial  or  extends  more  deeply.  At  times  also  a  pseudo-membrane  is 
found  on  the  ulcers. 

In  the  mtestines  swelling  of  Peyer's  follicles  is  not  uncommon.  In 
the  larynx  the  efflorescence  may  be  associated  with  a  fibrin  exudate,  and 

38 


594  PEDIATRICS 

sometimes  with  oedema  sufficient  to  cause  death.  Occasionally  the  inflam- 
mation extends  deeper  and  involves  the  cartilages.  In  the  trachea  and 
bronchi  there  may  be  ulcerative  erosions,  but  the  characteristic  lesions 
seen  on  the  skin  do  not  occur.  There  are  no  special  lesions  of  the  lungs, 
but  congestion  or  broncho-pneumonia  is  very  common. 

Conjunctivitis,  keratitis,  and  inflammation  of  other  parts  of  the  eye 
may  occur  in  the  course  of  the  disease  or  afterwards. 

Acute  otitis  media,  with  or  without  suppuration,  is  of  common  occur- 
rence. 

The  pathological  changes  in  the  other  organs  consist  of  enlargement  of 
the  spleen  and  fatty  degeneration  of  the  liver,  kidneys,  and  heart.  Meta- 
static processes  in  the  various  organs  and  in  the  joints  sometimes  occur.  In 
the  hemorrhagic  form  hemorrhages  in  the  various  cavities,  in  the  different 
organs,  and,  according  to  Golgi,  in  the  medullary  cavities  of  the  bones,  may 
occur,  also  in  the  serous  and  mucous  surfaces  and  in  the  muscles.  The 
blood  shows  an  active  leucocytosis  during  the  pustulous  stage,  and  the  red 
blood-corpuscles  tend  to  form  in  clumps  instead  of  rouleaux. 

Incubation. — The  incubation  of  the  disease  varies  from  twelve  to 
fourteen  days,  the  latter  being  the  most  frequent  period. 

Symptoms. — According  as  the  symptoms  of  variola  are  mild  or  severe 
the  disease  has  been  divided  into  a  number  of  forms,  designated  as  follows ; 
(1)  discrete,  (2)  confluent^  (3)  hemo^^rhagic,  and  (4)  modified.  In  all  these 
forms  the  initial  fever,  convulsions,  and  general  symptoms  may  be  severe, 
and  do  not  necessarily  indicate  which  type  of  the  disease  is  about  to  follow. 

(1)  Discrete  Form. — The  mildest  and  most  typical  form  of  the  dis- 
ease is  that  which  is  called  discrete. 

Prodromata. — In  this  form,  the  invasion,  although  sometimes  less 
severe  than  in  the  confluent  and  hemorrhagic  forms,  is  in  infants  and  young 
children  almost  always  of  a  grave  type.  In  infancy  and  early  childhood 
the  disease  commonly  begins  with  convulsions.  There  may  be  vomiting, 
great  restlessness,  rapid  pulse,  high  temperature,  and  in  a  number  of  cases 
^ — the  children  quickly  succumb  to  the  disease  from  the  virulence  of  the 
toxEemia.  If  they  survive  this  early  stage  of  the  disease  they  usually 
present  the  same  sequence  of  symptoms  as  in  cases  occurring  in  later 
life,  but  may  eventually  die  from  the  exhaustion  which  often  rises  from  a 
prolonged  suppurative  fever.  In  the  prodromal  stage  the  pulse  is  much 
accelerated  and  the  temperature  may  be  as  high  as  40°,  40.5°,  or  even 
41.1°  C.  (104°,  105°,  or  106°  F.).  In  this  stage  we  at  times,  especially 
among  children,  meet  with  an  evanescent  erythematous  efflorescence. 
According  to  Simon,  this  manifestation  is  distinct  from  that  of  scarlet 
fever.  It  has  a  peculiar  distribution  and  generally  a  limited  extent,  usu- 
ally affecting  the  lower  abdominal  areas,  the  inner  surface  of  the  thighs, 
the  sides  of  the  thorax,  and  the  axillae ;  sometimes,  however,  it  involves 
the  whole  surface.  This  efflorescence  is  distinct  from  the  typical  lesions 
of  variola  which  occur  later. 


SPECIFIC   INFECTIOUS   DISEASES.  595 

Efflorescence. — On  the  third  or  fourth  day  of  the  prodromal  symptoms 
an  efflorescence  appears  on  the  skin,  and  at  this  time  the  frequency  of  the 
pulse  lessens,  the  temperature  usually  falls  considerably,  and  the  more 
severe  symptoms  improve,  so  that  the  patient  appears  much  more  com- 
fortable. The  efflorescence  is  at  first  represented  by  small  red  macules 
or  papules,  which,  as  a  rule,  first  appear  on  the  forehead,  or  on  the  face 
and  mucous  membranes,  and  later  on  the  trunk  and  limbs.  The  papules 
are  rather  scattered  in  their  distribution,  and  have  a  feeling  as  of  shot 
under  the  skin.  The  macules  when  present  soon  become  papules.  On 
the  third  day  by  means  of  a  good  light  a  small  vesicle  can  be  seen  at  the 
apex  of  the  papule,  and  by  the  fifth  or  sixth  day  the  vesicular  stage  is  well 
established  and  the  vesicle  becomes  distinctly  umbilicated.  This  appear- 
ance on  careful  examination  can  also  be  seen  in  the  lesions  of  the  mucous 
membranes.  At  about  the  eighth  day  the  vesicles  become  pustules,  the 
tops  soon  flatten,  and  the  umbilication  disappears,  leaving  an  areola  of 
injection  and  the  intervening  skin  in  a  swollen  condition. 

Temperature. — The  temperature  at  this  time  rises,  from  the  suppuration 
which  is  taking  place  in  the  pustules.  This  rise  of  temperature  is  called 
the  secondary  fever,  or  fever  of  suppuration.  The  temperature  remains 
high  for  from  twenty-four  to  forty-eight  hours,  and  then  gradually  falls 
until  by  the  twelfth  or  thirteenth  day  it  usually  becomes  normal.  The 
contents  of  the  pustules  dry  up,  and  crusts  are  formed.  On  the  palms 
and  soles  small,  hard  disks  form,  which  may  of  themselves  fall  off  in 
infants,  but  in  children  as  old  as  ten  years  would  remain  for  a  long  time 
unless  removed  with  the  point  of  a  knife. 

Blood. — On  examining  the  blood  in  cases  of  variola  Arnheim  found 
the  haemoglobin  diminished  at  the  beginning  of  the  disease.  After  the  for- 
mation of  pustules  and  during  their  exsiccation,  he  found  an  increase  of 
the  haemoglobin  with  diminution  of  the  erythrocytes.  When  compli- 
cating suppuration  occurred  both  the  erythrocytes  and  the  haemoglobin 
remained  for  a  long  time  abnormally  diminished. 

Pick  in  forty-two  cases  found  no  leucocytosis  except  in  the  stage  of  sup- 
puration or  in  some  complication  like  pneumonia.  This  was  the  case  even 
when  the  temperature  was  high,  the  disease  severe,  and  the  termination 
fatal. 

Desquamation. — By  the  fourteenth  or  fifteenth  day  the  stage  of  desqua- 
mation is  established.  In  some  cases  extensive  scars  are  left  on  the  skin 
where  the  crusts  have  fallen  off.  This  is  most  apt  to  occur  in  severe 
cases. 

(2)  Confluent  Form. — In  contradistinction  to  the  mild  or  discrete 
form  of  variola  is  the  more  severe  form,  called  confluent,  on  account  of 
the  tendency  of  the  lesions  to  coalesce.  In  the  confluent  form  of  variola 
the  efflorescence  usually  appears  at  the  same  time  as  in  the  discrete  form. 
At  about  the  fourth  day  the  lesions  become  confluent,  the  skin  becomes 
reddened  and  swollen,  and  the  face  may  be  much  distorted  by  the  severity 


596  PEDIATRICS. 

of  the  lesions.  In  this  form  the  initial  temperature  does  not  fall  to  the 
same  degree  as  it  does  in  the  discrete  form,  and,  according  to  Sydenham, 
diarrhoea  is  likely  to  occur,  particularly  in  children.  The  pharynx  and 
larynx  are  especially  apt  to  be  involved,  and  the  cer\dcal  lymphatics  to  be 
enlarged.  The  crusts  adhere  longer  in  the  stage  of  desquamation  than 
they  do  in  the  same  stage  of  the  discrete  form. 

(3)  Hemorrhag-ic  Form. — The  third  or  hemorrhagic  is  the  most  viru- 
lent form  of  variola,  and  may  occur  in  children  as  it  does  in  adults, 
although  not  so  frequently  in  the  former  as  in  the  latter.  Its  symptoms 
in  children  are  so  severe  that  in  almost  every  case  it  very  quickly  proves 
fatal.  It  is  characterized  by  punctiform  hemorrhages  in  the  skin,  appear- 
ing from  the  first  to  the  fourth  day  of  the  prodromal  stage,  ecchymoses  in 
the  conjunctivae,  and  hemorrhages  from  the  mucous  membranes.  Accord- 
ing to  Osier,  hsematuria  is  the  most  common  form  of  hemorrhage,  hsema- 
temesis  the  next. 

(4)  Modified  Form. — The  fourth  or  modijied  form  of  variola  occurs 
when  the  disease  attacks  individuals  who  have  been  successfully  vacci- 
nated. This  form  is  called  varioloid,  but  would  be  better  termed  modified 
smaJl-pox.  Modified  small-pox  is  usually  much  milder  in  its  symptoms 
than  any  of  the  other  forms  of  variola,  although  the  initial  fever  may  be  as 
high  as  in  a  severe  case.  The  papules  are  fewer  in  number,  the  tempera- 
ture becomes  normal  sooner,  and  the  child  seems  comfortable  in  a  shorter 
period  of  time,  since  there  is  usually  no  secondary  fever  from  suppura- 
tion. The  nearer  the  attack  comes  to  the  time  when  the  child  was 
vaccinated,  the  less  severe  will  be  the  symptoms. 

In  any  of  these  forms  of  variola  the  prodromal  symptoms  may  be  of  a 
very  severe  nervous  type,  and  this  is  especially  characteristic  of  the  disease 
as  it  occurs  in  children.  For  this  reason  variola  may  simulate  other 
diseases  in  its  prodromal  stage,  and  may  often  cause  death  before  the 
efflorescence  has  appeared.  This  is  especially  the  case  Avith  the  prodromal 
symptoms  of  the  hemorrhagic  form. 

Complications. — The  most  common  complications  of  variola  are  those 
of  the  larynx  and  the  lungs.  When  the  larynx  is  affected,  oedema  of  the 
glottis  may  suddenly  arise  and  death  take  place  from  suffocation.  When 
a  lesion  of  the  lung  develops,  it  is  usually  in  the  form  of  a  broncho- 
pneumonia.    Lobar  pneumonia  rarely  complicates  the  disease. 

In  the  throat  the  presence  of  the  efflorescence  occasions  great  irrita- 
tion, and  the  accompanying  secretions  cause  nausea  and  at  times  dyspnoea, 
mth  a  cough  Avhich  in  weak  children  is  very  exhausting. 

When  acute  inflammation  of  the  middle  ear  has  taken  place  the  pain 
during  the  formation  of  the  pus  is  very  intense,  but  it  subsides  as  soon  as 
the  sac  bursts  or  is  incised.  This  complication,  therefore,  requires  early 
and  careful  treatment. 

Although  albumin  is  ybtj  frequently  present  in  the  course  of  the  dis 
ease,  nephritis  is  rare. 


SPECIFIC   INFECTIOUS   DISEASES. 


597 


The  follo^^^ng  chart  represents  the  usual  temperature  curve  of  the 
initial  fever  and  the  suppurative  fever  in  a  typical  case  of  variola. 


( 

:]HAKT 

25. 

I><zz^s  ofHisGtzse 

F 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

c 

107° 
106' 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

NOBM'L 
TEMD. 

98° 
97° 
96° 
95° 

M   E 

M  E 

M  E 

M  E 

M  E 

M   E 

M  E 

M  E 

M   E 

M  E 

>I   E 

M  E 

M  E 

M  E 

41.6° 

41.1° 

40.5° 

40.0° 

39.4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36  6° 

36.1° 

35.5° 

35.0° 

/ 

/ 

y 

l^ 

/ 

K 

V 

/ 

\ 

/ 

1 

h 

/ 

/ 

y 

/ 

V 

/ 

U 

' 

y 

l>. 

h 

V 

\r 

^ 

Fever  of  invasion.    Fever  of  suppuration,    ^'a^iola. 

Dl\gnosis. — There  is  no  other  constitutional  disease  accompanied  by 
an  efflorescence  on  the  skin  which  in  a  typical  case  would  be  likely  to  be 
mistaken  for  variola.  The  severe  constitutional  symptoms,  the  slowly 
developing  and  rather  scattered  macules  and  papules,  with  the  shotty  feel- 
ing of  the  latter,  the  umbilicated  vesicles  gradually  becoming  pustules,  the 
extensive  crust  formation,  and  the  initial  and  suppurative  fever,  all  render 
the  diagnosis  in  most  cases  cjuite  plain. 

Extreme  cases  of  varicella  have  been  mistaken  for  variola.  The  dif- 
ferential diagnosis  between  the  two  diseases  is  given  in  the  table  on 
page  606. 

Variola  differs  materially  in  its  prodromal  symptoms  from  measles,  in 
which  the  pronounced  catarrhal  symptoms  of  the  nose  and  eyes  make 
the  differentiation  comparatively  easy.  Although  the  prodromal  symp- 
toms of  scarlet  fever  and  of  variola,  such  as  the  convulsions  and  vomiting, 
are  often  of  equal  severity  and  somewhat  similar,  yet  the  pronounced 
symptoms  connected  with  the  throat  in  scarlet  fever,  and  the  appearance 
of  an  erythematous  efflorescence,  instead  of  the  scattered  papules  of 
variola,  serve  to  differentiate  clearly  the  two  diseases.  We  must,  how- 
ever, be  careful  not  to  mistake  the  evanescent  efflorescence  which  occurs 
in  the  prodromal  stage  of  variola  for  the  erythema  of  scarlet  fever.  The 
distinction  can  usually  be  made  by  remembering  that  the  efflorescence  in 
variola  has  the  peculiar  distribution  described  under  prodromata  on  page 
594,  while  the  typical  location  of  the  efflorescence  of  scarlet  fever  is 
first  on  the  neck  and  chest. 


598  PEDIATRICS. 

In  making  the  diagnosis  of  variola  we  must  bear  in  mind  tlie  efflores- 
cence which  appears  on  the  skin  in  the  course  of  a  general  vaccinia.  In 
vaccination  the  single  lesion  and  the  absence  of  severe  constitutional 
symptoms  make  it  hardly  necessary  to  do  more  than  refer  to  it  in  this 
connection.  The  differential  diagnosis  from  general  vaccinia  is  not  difficult, 
and  yet  general  vaccinia  is  so  rarely  met  with  that  when  it  appears  it 
almost  always  creates  a  suspicion  that  we  may  be  dealing  with  variola.  As 
a  rule,  in  vaccinia  the  general  symptoms  are  not  severe,  the  disease  being 
represented  almost  entirely  by  a  slight  malaise  and  loss  of  appetite,  in  con- 
junction with  the  appearance  on  the  third  or  fourth  day  of  an  efflorescence 
on  the  skin,  represented  by  papules,  vesicles,  and  pustules,  few  in  number 
and  irregularly  distributed,  some  on  the  face  and  nose  and  a  few  on  the 
body  and  extremities.  As  these  manifestations  almost  invariably  appear 
after  vaccination,  this  fact  is  of  great  aid  in  the  differential  diagnosis  from 
variola.  The  subsequent  course  of  a  case  of  vaccinia  is  so  much  milder 
and  shorter  than  that  of  variola  that  in  a  few  days  the  differential  diagnosis 
can  be  made  easily. 

Prognosis. — The  prognosis  of  variola  depends  upon  whether  the  child 
has  been  vaccinated,  and  also  upon  whether  children  who  have  been  vac- 
cinated when  infants  have  been  revaccinated.  In  the  unvaccinated  the 
prognosis  is  always  bad,  and  is  proportionately  grave  the  younger  the 
child.  In  the  vaccinated  the  prognosis  is  good,  and  is  favorable  pro- 
portionately to  the  shortness  of  the  interval  between  the  invasion  of  the 
variola  and  the  time  of  the  previous  vaccination. 

Treatment. — There  is  no  specific  treatment  for  variola,  but  it  is  of  the 
utmost  importance  that  the  best  hygienic  care  should  be  employed.  The 
air  of  the  room  should  be  perfectly  fresh.  The  crusts  should  be  kept 
softened  with  a  mixture  of  glycerin,  oil,  and  carbolic  acid,  and  the  odor 
arising  from  them  should  be  modified  by  the  application  of  a  dilute 
solution  of  carbolic  acid.  The  general  principles  of  treatment  are  the 
same  as  in  any  severe  acute  infection. 

In  the  initial  stage  of  the  disease  stimulants  should  be  freely  given  if 
the  symptoms  are  severe,  and  the  high  temperature  should  be  controlled 
by  sponging  with  water  at  a  temperature  corresponding  to  the  powder  of 
the  child's  reaction. 

The  greatest  care  should  be  taken  during  the  stage  of  convalescence, 
and  when  the  child  is  considered  well  the  most  rigid  measures  for  pre- 
venting the  spread  of  the  contagium  should  be  enforced.  The  clothing 
and  everything  connected  with  the  child  and  its  attendants,  and  the  room 
in  which  they  have  been  kept  during  the  sickness  of  the  child,  should  be 
thoroughly  disinfected,  the  same  precautions  being  taken  to  prevent  the 
spread  of  variola  as  in  scarlet  fever.  The  immediate  transferrence  of  a 
patient  from  its  room  to  a  small-pox  hospital  is  in  most  communities  con- 
sidered the  wisest  method  of  dealing  with  the  disease,  and  is  usually 
enforced  by  law. 


SPECIFIC   INFECTIOUS   DISEASES.  599 

VACCINIA. 

Vaccinia  (cow-pox)  is  a  specific  eruptive  disease  occurring  in  cattle, 
especially  in  cows.  Councilman  has  found  in  vaccinia  an  organism  re- 
sembling that  found  in  small-pox.  He  describes  it  under  the  name  of 
cytoryctes  vacciniae.  The  disease  in  human  beings  may  be  either  a  local 
affection,  spreading  from  a  point  of  inoculation,  such  as  from  vaccination, 
or  may  be  a  general  manifestation  arising  from  the  entrance  of  poisonous 
matter  into  the  blood.  It  is  supposed  that  vaccinia  may  occur  either  by 
the  introduction  of  the  vaccine  lymph  into  the  blood  or  by  auto-inocu- 
lation, and  that  the  latter  is  probably  the  more  common  way.  The 
disease  is  characterized  by  the  appearance  of  papules,  vesicles,  and 
pustules  of  different  sizes  in  different  parts  of  the  body  and  limbs,  as  well 
as  on  the  face,  and  running  a  definite  course.  It  may  be  said  to  be  a 
rather  rare  disease.  When  its  lesions  follow  vaccination  they  appear  at 
about  the  fifth  day  after  the  inoculation.  At  the  end  of  four  days,  however, 
minute  vesicles  can  be  seen  with  the  magnifying-glass. 

Vaccination. — By  vaccination  is  commonly  meant  the  inoculation 
with  the  virus  of  vaccinia  as  a  preventive  of  variola.  During  a  period  of 
fifteen  years  no  death  has  occurred  from  variola  in  Boston  of  a  child  who 
had  been  vaccinated  before  it  was  five  years  old.  During  the  same 
period  the  percentage  of  deaths  among  the  unvaccinated  at  the  Boston 
Small-Pox  Hospital  was  seventy-five  per  cent.,  while  that  of  the  vacci- 
nated was  three  per  cent.  For  the  past  seventeen  years  no  person  who 
has  been  successfully  vaccinated  within  five  years  has  died  of  variola,  and 
those  who  have  been  attacked  by  variola  have  had  the  disease  in  a  very 
mild  form.  In  order  to  show  the  relative  frequency  of  deaths  occurring 
in  the  vaccinated  and  in  the  unvaccinated  we  have  arranged  the  following 
table,  based  on  a  report  by  Dr.  Barry  of  an  epidemic  of  variola  at  Shef- 
field, England,  during  1887  and  1888.  The  table  shows  the  percentage 
of  those  who,  living  in  houses  invaded  by  variola,  were  attacked  by  the 
disease,  and  also  how  many  of  these  died.  It  also  gives  the  percentages 
for  all  ages,  and  for  those  under  ten  years  and  over  ten  years. 

TABLE    62. 

Individuals  living  in  Houses  invaded  hy  Variola. 

1.  2.  3. 

All  ages.       Over  ten  years.  Under  ten  j'ears. 

Per  Cent.  Per  Cent  Per  Cent, 

^      .     ^j               f  Attacked 23.0  28.1  7.8 

^"^^^""'^*^ JDied 1.1  1.4  0.1 

rnvaccinated.  .  . .  |  ^.^^f  ^ed 75.0  68.0  89.9 

I  Died 37.2  37.1  38.1 

The  low  percentage  of  children  as  shown  in  column  3  is  very  striking 
in  comparison  with  column  2,  which  represents  older  individuals,  and 
enunciates  the  importance  of  re  vaccination.  It  also  impresses  upon  us 
the  significance  of  the  difference  in  the  number  of  deaths  between  the 


goo  PEDIATRICS. 

vaccinated  and  the  unvaccinated.  When  large  numbers  of  cases  of 
variola  have  been  reported  figures  show  that  among  the  vaccinated  nine- 
teen out  of  twenty  recover,  while  of  the  unvaccinated  fifty  mdividuals 
out  of  one  hundred  die.  It  is  therefore  evident  that  vaccination  is  highly 
protective  against  variola,  and  physicians  should  insist  on  the  vaccination 
of  every  individual  in  the  community.  One  vaccination,  however,  does 
not  protect  for  a  lifetime.  On  the  contrary,  re  vaccination  is  just  as  im- 
portant as  the  primary  operation.  One  attack  of  variola  does  not  always 
protect  an  individual  from  a  second  invasion,  and  more  should  not  be 
expected  from  vaccination. 

Revaccination  should  be  performed  at  intervals  of  eight  or  ten  years, 
and  in  a  shorter  time  when  cases  of  variola  appear  in  a  community.  The 
danger  of  serious  results  arising  from  vaccination  is  extremely  small. 

The  time  at  which  vaccination  should  be  done  is  of  considerable  im- 
portance. The  infant  should  be  vaccinated  early,  before  it  begins  to  be 
exposed  to  the  danger  of  contagion  from  sources  outside  of  its  home. 
We  must,  however,  remember  how  low  is  its  vitality  at  birth,  and  how 
readily  this  vitality  is  affected  by  Avhat  would  be  considered  trifling  con- 
ditions for  the  older  child  or  for  the  adult.  A  time  should  be  chosen 
when  the  infant  is  not  subject  to  the  other  disturbing  conditions  which 
naturally  arise  in  the  first  two  years  of  life,  such  as  weaning  and  the  irri- 
tation of  the  dental  periods.  If  it  is  found  necessary  to  vaccinate  the 
infant  after  the  sixth  or  seventh  month,  or  before  the  twentieth,  it  should 
be  done  in  an  interdental  rather  than  in  a  dental  period,  and  not  at  the 
time  when  its  food  is  being  changed,  or  when  it  is  suffering  from  either 
slight  catarrhal  conditions  or  some  definite  disease.  We  prefer  to  vaccinate 
the  infant  when  it  is  four  or  five  months  old, — that  is,  just  before  the 
period  when  the  first  tooth  appears.  At  this  age  it  has  usually  become 
accustomed  to  its  food,  its  digestion  is  in  equihbrium,  and  its  vitality  is 
much  above  what  it  was  in  the  early  weeks  of  its  life.  By  the  fifth 
month  also  it  will  usually  have  developed  the  outward  symptoms  of 
syphilis  if  it  has  inherited  that  disease  from  its  parents. 

The  vaccine  virus  can  be  introduced  into  any  part  of  the  body  through 
the  skin,  and  according  to  the  fancy  of  the  physician  or  parents.  Girl 
infants  can  be  vaccinated  just  below  the  knee  on  the  outer  side  of  the  leg, 
so  as  to  avoid  having  a  scar  on  the  arm,  to  which  women  usually  object. 
We  are  accustomed  to  vaccinate  boys  on  the  outer  side  of  the  upper  arm. 
Whether  the  vaccination  is  performed  upon  the  leg  or  the  arm,  we  should 
first  inquire  if  the  person  who  is  to  take  care  of  the  infant  is  right- 
handed  or  left-handed.  If  the  nurse,  for  instance,  is  right-handed,  she 
will  naturally  hold  the  infant  on  her  left  arm,  and  in  this  case,  the  infant's 
right  arm  being  towards  the  nurse,  it  is  better  for  the  vaccination  to  be 
on  the  left  arm.  The  process  should  be  reversed  when  the  nurse  is 
left-handed,  and  in  this  case,  for  the  same  reason,  it  is  better  to  vaccinate 
on  the  right  arm  or  leg.    The  form  of  virus  which  we  have  been  accus- 


PLATE  X. 


Vaccine  Quill. 


•#& 


Vaccination  Scratch. 


At  5th  Day. 


At  8th  Day. 


At  10th  Day. 


At  12th  Day, 


# 


At  16th  Day. 


At  19th  Day. 


Scar  at  1  Year. 


Scar  at  21  Years. 


SPECIFIC   INFECTIOUS   DISEASES.  601 

tomed  to  use,  and  which  we  consider  the  best,  is  taken  from  cows  rather 
than  from  human  beings.  It  should  be  very  carefully  prepared  by  those 
who  have  made  a  scientific  study  of  the  subject,  and,  if  possible,  on  farms 
which  are  under  state  supervision. 

It  has  been  very  well  proved  by  careful  observation  of  large  num- 
bers of  primary  vaccinations  that  those  who  in  later  life  contract  variola 
have  the  disease  in  a  less  severe  form  when  in  their  primary  vaccinations 
they  have  been  inoculated  in  three  places  at  once  rather  than  in  two,  and 
in  two  places  at  once  rather  than  in  one.  The  general  constitutional 
disturbance  also  does  not  appear  to  be  greater  when  the  inoculation  has 
been  in  two  or  three  places  rather  than  in  one.  The  evidence  therefore 
seems  to  be  in  favor  of  inoculating  in  two  or  three  places  in  primary 
vaccinations.  A  very  small  surface  is  amply  sufficient  for  the  proper  in- 
troduction of  the  virus.  A  pointed  ivory  quill  charged  with  glycerinated 
lymph  (such  as  is  shown  in  Plate  X.)  can  be  used  directly  for  removing 
the  epithelium,  for  exposing  the  smaller  blood-vessels,  and  for  introducing 
the  virus.  We  prefer  not  to  use  any  more  instruments  than  possible,  in 
order  to  avoid  the  possible  introduction  of  some  foreign  substance  which 
might  interfere  with  the  natural  course  of  the  vaccine  virus  and  cause 
unnecessary  inflammation. 

The  utmost  precaution  should  be  taken  to  insure  against  infection 
from  other  micro-organisms  besides  the  vaccine  virus.  The  part  of  the 
skin  chosen  for  the  vaccination  should  be  thoroughly  washed  with  soap 
and  water  and  with  alcohol.  The  hands  of  the  operator  should  be  clean 
and  aseptic.  A  series  of  short  scratches  should  be  made  about  one-half 
centimetre  (about  one-fourth  inch)  long,  four  or  five  in  number,  and  in 
two  sets,  one  crossing  the  other,  until  the  epithelium  is  sufficiently  re- 
moved to  show  that  the  blood-vessels  are  exposed,  but  not  to  a  degree 
that  bleeding  should  take  place,  for  in  the  latter  case  the  virus  may  be 
prevented  from  gaining  an  introduction  to  the  general  circulation.  The 
point  of  the  cpill  should  then  be  dipped  into  water  which  has  been  freshly 
sterilized.  The  flat  part  of  the  quill  which  is  charged  with  the  virus  is 
then  thoroughly  rubbed  into  the  wound.  The  skin  should  be  protected 
for  four  or  five  minutes  from  contact  with  anything  and  then  sealed  with 
aseptic  cotton  and  collodion.  After  two  days  this  cotton  can  be  removed, 
and,  unless  the  subsequent  lesion  is  broken,  this  measure  is  an  additional 
safeguard  against  infection  from  extraneous  matter  in  the  first  few  days. 

Plate  X.  shows  the  different  stages  of  a  vaccination  as  they  occurred 
in  one  case  carefully  observed  by  the  artist  and  myself  every  day.    . 

On  the  fifth  day,  as  shown  in  the  plate,  a  round,  clear  vesicle  was  seen  at  one  end 
of  the  vaccination  scratch,  while  at  the  other  end  there  happened  to  he  left  a  little 
brown  crust. 

On  the  eighth  day  an  irregular-shaped  lesion  about  |  cm.  (J  inch)  long,  and  1  cm. 
(^  inch)  wide,  somewhat  depressed  in  the  middle,  and  with  a  clear  vesicular  border, 
appeared. 


602  PEDIATRICS. 

On  the  tenth  day  the  lesion  had  increased  in  length  to  2  cm.  (^  inch)  long,  and  to 
a  little  over  1  cm.  (^  inch)  wide,  and  there  was  an  erythematous  condition  of  the  skin 
forming  an  areola  with  a  diameter  of  about  2  cm.  (J  inch),  in  the  middle  of  which 
was  the  lesion  just  described.  This  areola  was  of  a  light  shade  of  red,  and  on  its  outer 
border  were  irregularly  distributed  little  light  red  maculae. 

On  the  twelfth  day  very  nearly  the  same  appearances  were  present  as  on  the  tenth 
day,  except  that  the  areola  was  very  much  more  intense  in  its  red  color,  and  had  grown 
to  the  size  of  a  circle  3  cm.  (l'|-  inches)  in  diameter.  Some  of  the  little  macute  had 
become  vesicles. 

On  the  sixteenth  day,  in  place  of  the  vesicular  lesion  with  its  depressed  centre,  a 
crust  had  formed  with  a  narrow  line  of  redness  around  it,  and  on  the  outer  border  of 
this  areola  the  redness  gradually  became  fainter  and  shaded  off  into  the  normal  skin. 

On  the  nineteenth  day  the  crust  was  smaller,  the  redness  had  disappeared,  and 
where  the  areola  was  most  pronounced  there  was  a  slight  desquamation. 

A  vaccination  scar  at  one  year  and  twenty-one  years  is  also  shown  in  the  plate. 

Every  case  of  vaccination  does  not  present  exactly  the  same  appear- 
ances. The  lesions  may  differ  in  shape  and  size,  and  one  individual  may 
be  affected  more  intensely  by  the  virus  than  another ;  one  may  have 
accompanying  severe  constitutional  symptoms  and  another  have  none. 
The  chain  of  lymphatics  may  be  affected  as  far  as  the  axilla  or  the 
groin. 

As  a  rule,  the  following  description  represents  pretty  well  the  usual 
course  of  the  disease.  After  the  vaccination,  the  skin  shows  nothing  new 
until  the  third,  fourth,  or  even  fifth  day,  when  a  small  red  point  appears. 
This  soon  becomes  a  papule ;  by  the  next  day  a  vesicle  is  developed ; 
about  the  sixth  day  this  vesicle  usually  becomes  umbilicated,  and  is  sur- 
rounded by  a  faint  red  zone.  By  the  eighth  day  the  vesicle  is  fully  de- 
veloped, and  by  the  ninth  day  the  red  zone  increases  rapidly  and  the 
vesicle  soon  becomes  a  pustule.  By  the  eleventh  or  twelfth  day  a  crust 
is  formed,  and  this  crust  falls  off  from  about  the  fourteenth  to  the  twenty- 
first  day,  in  some  cases  an  ulcer  being  left  which  heals  by  another  crust 
being  formed,  in  others  the  skin  remaining  intact.  From  the  eighth  to  the 
twelfth  day  there  may  be  a  slight  amount  of  fever  and  coated  tongue, 
jvith  some  loss  of  appetite,  and  the  glands  of  the  axilla  or  groin  may  be- 
come enlarged  and  tender.  The  scar,  although  perhaps  not  typical,  can 
usually  be  recognized  by  its  small  depressions  (pits)  and  its  location. 

In  some  cases,  instead  of  the  healing  of  the  scratch  in  a  few  days,  or 
the  formation  of  the  vesicle  of  a  successful  vaccination,  irregular  excres- 
cences of  a  fungus-like  character  may  appear.  These  in  all  probability 
have  no  connection  with  the  true  vaccine  virus,  and  are  not  protective. 
In  addition  to  the  rather  rare  cases  of  vaccinia,  various  efflorescences  at 
times  appear  on  the  skin,  not  only  in  the  neighborhood  of  the  vaccination 
lesion,  but  also  in  other  parts  of  the  body.  They  may  be  present  on  the 
fourth  or  fifth  day,  or  even  later,  in  the  second  week,  and  are  probably 
caused  by  some  reflex  connection  with  the  vaccination  lesion.  They  vary 
considerably  in  form,  but  are  usually  represented  by  a  multiple  or  papu- 
lar erythema  or  an  urticaria.     It  should  be  remembered,  when  an  un- 


SPECIFIC   INFECTIOUS   DISEASES.  603 

vaccinated  child  has  been  exposed  to  variola,  that  if  it  is  vaccinated 
witliin  forty-eight  hours  it  will  probably  be  protected,  and  if  within  five 
or  six  days  the  variola  poison  will  be  so  modified  as  to  produce  only  a 
mild  form  of  the  disease. 

VARICELLA. 

Variceha  (chicken-pox)  is  the  mildest  in  its  symptoms  and  the  most 
favorable  in  its  prognosis  of  the  whole  group  of  exanthemata.  Tyzzer, 
who  has  made  extended  investigations  in  the  pathology  of  varicella,  be- 
lieves that  a  cell  which  he  fmds  in  the  vesicles  is  pathognomonic  of 
varicella  when  present,  but  that  when  absent  does  not  exclude  varicella. 
He  also  believes  that  this  cell  is  not  present  in  the  vesicle  of  small-pox. 
Varicella  is  highly  infectious,  and  is  characterized,  in  distinction  from 
the  other  exanthemata,  by  its  long  stage  of  incubation,  the  shortness  or 
absence  of  any  prodromal  stage,  its  vesicular  efflorescence,  and  the  absence 
of  sequelae.    . 

Etiology. — Varicella  has  been  known  as  an  independent  disease  for  the 
last  two  centuries.  At  one  time  it  was  not  clearly  differentiated  from 
measles  and  scarlet  fever,  and  in  some  parts  of  the  world  it  is  supposed 
to  be  closely  allied  to  variola.  This  opinion,  however,  is  not  generally 
substantiated,  and  we  can  accept  varicella  as  a  distinct  disease.  It  can 
occur  at  any  age,  but  the  most  common  time  for  its  appearance  is  in  the 
middle  and  latter  part  of  the  first  year.  It  continues  to  be  a  common 
disease  all  through  the  early  and  middle  years  of  childhood.  The  suscep- 
tibility to  the  contagium  of  varicella  lessens  after  ten  years  of  age,  and 
almost  disappears  at  puberty.  It  is  sometimes  sporadic  and  sometimes 
epidemic.  It  occurs  with  equal  frequency  at  all  periods  of  the  year. 
The  vehicle  of  contagium  is  not  known,  but  it  probably  enters  the  system 
by  the  lungs.  The  specific  organism  which  produces  varicella  has  not  yet 
been  determined. 

Pathological  Anatomy. — Deaths  from  varicella  are  so  extremely  rare 
that  our  knowledge  of  the  pathology  of  the  disease  is  necessarily  limited. 
It  is  evident,  however,  that  the  efflorescence  of  vesicles,  which  represents 
the  principal  morbid  lesion  of  the  disease,  is  of  a  somewhat  different  type 
from  that  which  occurs  in  variola.  The  vesicle  is  much  nearer  the  sur- 
face than  in  the  latter  disease,  being  formed  mostly  by  the  upper  layers 
of  the  epithelium.  The  vesicle  itself  is  seldom  multilocular,  a  condition 
which  is  frequently  present  in  variola.  The  contents  of  the  vesicles  are 
usually  a  clear  serum,  the  progression  to  a  pustule  being  rare  in  compari- 
son with  the  lesion  of  variola.  The  lesion  so  rarely  involves  the  deeper 
layers  of  the  skin,  and  the  process  is  usually  so  very  mild,  that  it  is  sel- 
dom that  sufficient  destruction  of  the  tissue  takes  place  to  produce  a 
scar. 

The  lesions  may  appear  on  the  mucous  membranes  as  well  as  on  the 
skin.     At  times  the  lesions  assume  a  much  more  serious  form  and  may 


604  PEDIATRICS. 

become  gangrenous.  In  gangrenous  varicella^  according  to  Eustace  Smith, 
the  vesicles,  instead  of  drying  up  in  the  ordinary  way,  become  black  and 
larger,  so  that  a  number  of  rounded  black  crusts  are  scattered  over  the 
surface  of  the  body.  If  a  crust  be  removed,  it  is  found  to  cover  an  ulcer 
more  or  less  deep.  Around  it  the  skin  is  of  a  dusky  red  color.  All  the 
vesicles  do  not  become  gangrenous,  so  that  we  find  crusts  of  the  ordinary 
appearance  mixing  with  the  blackened  crusts.  The  gangrenous  process 
often  penetrates  deeply  through  the  skin  to  the  muscles.  The  lesions  at 
times  are  so  extensive  as  to  form  ulcers  which  may  invade  and  destroy 
large  areas  of  tissue. 

Incubation. — The  stage  of  incubation  is  variable,  but  lasts  from  eight 
or  ten  days  to  three  weeks,  the  usual  time  being  about  seventeen  or  eigh- 
teen days. 

Symptoms. — Prodromata. — There  are  rarely  any  prodromata  in  vari- 
cella, beyond  a  slight  malaise  for  a  few  hours.  At  times,  however,  espe- 
cially in  young  infants,  the  onset  of  the  disease  may  be  severe :  it  may  be 
characterized  by  vomiting,  and,  when  the  temperature  is  high,  even  by 
convulsions.  In  rare  cases  the  prodromal  stage  is  of  considerable  length 
and  the  prodromata  resemble  somewhat  those  of  the  other  exanthemata. 

Effiorescence. — The  disease  usually  shows  itself  in  the  form  of  an 
efflorescence,  the  characteristic  and  most  common  lesion  of  which  is  a 
vesicle.  The  lesion,  however,  is  in  the  beginning  a  macule,  which  quickly 
becomes  a  papule,  and  the  papule  so  rapidly  develops  into  a  vesicle  that 
it  is  in  the  vesicular  stage  that  we  usually  first  notice  the  efflorescence. 
These  macules  and  papules  are  so  superficial  that  they  are  soft  to  the 
touch  and  do  not  give  the  shotty  feeling  which  is  so  common  in  these 
lesions  when  they  occur  in  variola.  The  vesicle  of  varicella,  as  a  rule,  is 
not  umbihcated,  and  its  contents  but  rarely  become  pustular.  It  may 
be  surrounded  by  a  light  red  areola,  but  this  is  not  present  in  all  the 
lesions.  The  usual  course  of  progression  in  the  lesions  is  that  the  vesicle 
flattens,  its  contents  are  dispersed  on  the  skin  or  absorbed,  and  a  small 
^ — crust  is  formed,  which  finally  falls  off,  leaving  the  skin  smooth  and  with- 
out a  scar.  Occasionally  a  scar  results  from  some  individual  lesion  in 
which  the  inflammatory  process  has  involved  the  deeper  layers  of  the 
skin.  The  efflorescence  is  irregular  and  general  in  its  distribution,  the 
lesions  appearing  on  the  face  and  head,  in  our  experience  especially  behind 
the  ears,  on  the  body,  usually  first  on  the  back,  and  finally  on  the  extremi- 
ties. It  comes  out  in  successive  crops,  so  that  very  different  lesions  may 
be  found  on  the  skin  at  once,  representing  the  early  and  late  manifesta- 
tions of  the  efflorescence.  It,  however,  may  first  appear  in  the  throat 
but  is  not  so  often  seen  in  this  location  as  is  the  efflorescence  of  scarlet  fever 
or  measles.  It  is  possible  that  the  efflorescence  always  appears  first  in 
the  throat,  but  that  in  many  cases  it  is  not  seen  early  enough  to  be  recog- 
nized, as  the  manifestations  are  very  evanescent. 

This  efflorescence  of  varicella  is  almost  the  only  one  which  is  charac- 


SPECIFIC    INFECTIOUS   DISEASES. 


605 


teristic  of  a  specific  disease.  By  tliis  we  mean  that  wliile  a  vesicle  does  not 
necessarily  allow  us  to  diagnosticate  any  disease  of  the  skin,  yet  when 
these  vesicles  ^nth  their  areolae,  in  combination  with  constitutional  symp- 
toms, appear  in  groups  in  different  parts  of  the  body,  there  is  no  other 
disease  with  which  we  should  be  likely  to  confound  it,  with  the  exception 
of  variola,  vaccinia,  and  possibly  herpes  zoster. 

The  temperature  in  varicella  is  in  most  cases  not  high,  and  is  very 
irregular.  It  usually  rises  when  a  crop  of  lesions  of  any  considerable 
number  develops,  and  falls  again  at  the  outbreak. 


CHAET  2r,. 


Daz/s  of  Disease 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

MORML 

^^98° 
97° 
96° 
95° 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

M   E 

M  E 

ME 

II  E 

H  E 

M  E 

d  E 

«  E 

«   E 

M   E 

\ 

y 

i 

/ 

/ 

/ 

/ 

f 

/ 

\  i 

> 

V 

V 

/-.. 

— . 

.... 

V 

V 

j^ 

i 

416° 

41.1° 

40.5° 

40.0° 

33.4° 

33.8° 

38.3° 

37.7= 

37.2= 
37.0= 
36  6= 

36.1° 

35.5° 

35.0° 


Varicella  simplex. 

Chart  26,  on  page  605,  shows  the  temperature  in  a  typical  case  of 
varicella  simplex. 

Diagnosis. — The  diagnosis  of  varicella  is  not  difficult  if  we  bear  in 
mind  the  characteristics  of  the  diseases  which  it  is  most  apt  to  simulate. 

From  Variola. — In  differentiating  it  from  variola  we  must  consider  the 
great  difference  in  the  rapidity  of  the  development  of  the  eftlorescence  in 
the  two  diseases.  In  variola  it  is  essentially  slow,  in  varicella,  it  is  char- 
acteristically quick.  The  papules  of  variola  are  hard  to  the  touch,  those 
of  varicella  are  soft.  The  vesicle  of  variola,  as  a  rule,  is  umbihcated  and 
soon  becomes  a  pustule  ;  these  characteristics  are  absent  in  varicella. 
The  whole  course  of  variola  occupies  a  period  of  from  two  to  three 
weeks  ;  the  course  of  varicella  is  much  shorter,  and  is  often  limited  to 
one  week.  Finally,  the  severe  constitutional  symptoms  and  the  long 
prodromal  stage  in  variola  differ  essentially  from  the  lack  of  prodromata 
and  the  mild  constitutional  symptoms  in  varicella. 

From  Vaccinia. — In  vaccinia  the  slow  progression  of  the  lesions  from 


606  PEDIATRICS. 

papules  to  pustules,  and  the  rather  Hmited  areas  affected,  serve  to  dis- 
tmguish  it  from  the  successive  crops  of  vesicles,  with  their  rapid  develop- 
ment and  extensive  areas,  which  are  met  with  in  varicella. 

From  Herpes  Zoster. — The  differential  diagnosis  of  varicella  from  her- 
pes zoster  is  not  difficult,  if  we  consider  that  the  vesicular  efflorescence  in 
herpes  zoster  follows  the  course  of  some  set  of  nerves,  while  that  of  vari- 
cella is  perfectly  irregular  and  is  in  no  way  connected  with  the  distribu- 
tion of  the  nerves. 

The  course  of  varicella  is  rapid.  It  is  characterized  by  a  sudden  onset 
of  constitutional  symptoms,  with  the  almost  immediate  appearance  of  the 
efflorescence.  The  efflorescence  runs  a  rapid  course,  appearing  quickly 
on  different  parts  of  the  skin,  and  disappearing  almost  as  quickly  as  it 
appears.  The  disease  lasts  about  a  week  or  ten  days,  and,  as  a  rule,  has 
no  serious  sequelae.     It  is  rarely  complicated  by  any  other  disease. 

Complications. — During  the  course  of  certain  epidemics,  however,  it 
has  been  noticed  that  the  kidney  is  affected.  This  complication  usually 
occurs  after  the  efflorescence  has  almost  disappeared,  and  in  the  second 
week  from  the  time  of  the  beginning  of  the  attack.  In  these  cases  albu- 
minuria is  present,  and  in  all  probability  is  caused  by  some  form  of 
nephritis,  although  nothing  definite  is  known  about  this  class  of  cases. 

Gangrenous  Varicella. — A  complication  which  at  times  arises  in  vari- 
cella is  what  is  called  the  gangrenous  form  of  varicella.  Although  it  is 
most  common  in  ill-nourished  children,  yet  it  does  not  necessarily  attack 
this  class  of  cases,  and  it  seems  to  have  some  connection  with  the  gan- 
grenous processes  which  certain  indi\iduals  show  a  tendency  to  develop. 

The  follo^^lng  table  gives  the  chief  points  of  difference  between  varicella 
and  variola : 

TABLE    68. 

Varicella.  Variola. 

Incubation Two  to  three  weeks.  One  to  two  weeks. 

Prodromata None  or  slight.  Three    to   four    days   in   length. 

Active.     Severe. 

Efflorescence Rapidly  becomes  vesicular.     Xot     A  slow  progressive   development 

umbilicated.  Unilocular.  Ir-  from  a  macule  to  a  papule,  from 
regular.  Lesions  numerous.  a  papule  to  an  umbilicated  vesi- 
TJniversally  distributed  in  sue-  cle,  then  to  a  pustule,  ilulti- 
cessive  crops.  Vesicles  differ  locular.  Eegular.  Lesions  not 
greatly  in  size.  On  pricking,  numerous.  Defined  in  its  locali- 
collapses  entirely.  zation.     Lesions,  as  a  rule,  of 

uniform  size.  On  pricking,  col- 
lapses partially. 

Desquamation Slight  crust  formation.  Pronounced  crust  formation. 

Duration Short,  one  week  to  ten  days.  Long,  three  to  four  weeks. 

Type Mild.  Severe. 

Temperature Irregular,  not  high.  Eises  suddenly.      Remains   high 

until  papules  are  developed, 
when  it  falls  considerably. 
Eises  again  during  the  develop- 
ment of  the  pustules. 


PLATE  XI. 


Krysipelas. 


Varicella. 


Syphilis. 


SPECIFIC   INFECTIOUS   DISEASES.  607 

Prognosis. — The  prognosis  of  varicella  is  usually,  unless  the  above- 
mentioned  complications  arise,  extremely  favorable.  Cases  occur  in  which 
the  prognosis  is  rendered  unfavorable  by  lack  of  proper  care  during  the 
convalescence,  resulting  in  broncho-pneumonia  and  other  diseases.  In 
some  cases  the  prognosis  is  rendered  unfavorable  by  the  anaemia  which 
is  apt  to  follow  an  attack  of  varicella,  and  is  at  times  pronounced. 

Treatment. — ^The  treatment  of  varicella  is  simply  sjTiiptomatic.  The 
child  should  stay  in  the  house,  and  its  room  should  be  kept  at  an  even 
temperature.  The  diet  should  be  milk.  The  child  should  be  carefully 
watched  to  prevent  it  from  scratching,  as  lesions  deep  enough  to  produce 
scars  may  often  be  obviated  in  this  way.  This  treatment  should  be  con- 
tinued mitil  all  the  constitutional  symptoms  have  passed  away  and  the 
efflorescence  has  disappeared.  Complete  isolation  should,  if  possible,  be 
enforced,  as,  although  the  disease  is  usually  insignificant,  we  can  never  in 
the  beginning  determine  whether  or  not  a  rare  and  severe  case  is  about 
to  develop. 

These  rules  for  treatment  are  precautionary,  and  are  based  on  the 
supposition  that  a  child  who  has  had  a  constitutional  disease  of  this 
nature  must  be  more  sensitive  to  exposure  of  various  kmds.  As  it  is 
possible  in  some  cases  for  the  kidney  to  be  affected  in  the  later  stages  of 
the  disease,  just  as  it  is  m  scarlet  fever,  it  is  well  to  guard  against  this 
complication  by  the  protection  of  the  skin  from  changes  of  temperature 
and  by  the  use  of  milk  as  a  diet.  In  a  considerable  number  of  cases, 
especially  in  yomig  children,  an  anaemia  of  greater  or  less  degree  results 
from  the  disturbance  of  nutrition  which  so  often  accompanies  the  disease. 
In  these  cases  the  administration  of  saccharated  carbonate  of  iron  or  of 
tartrate  of  iron  and  potash  is  indicated. 

The  following  case  represents  an  ordinan'  attack  of  varicella.  A  boy 
was  brought  to  the  hospital  to  be  treated  for  a  supposed  cold.  On  ex- 
amination nothing  abnormal  was  found  except  the  lesions  shoAvn  in  the 
throat  in  Plate  XI. 

The  tongue  was  very  slightly  coated.  The  tonsils  vrere  not  enlarged.  The  mucous 
membrane  of  the  hard  and  of  the  soft  palate  and  of  the  pharynx  was  slightly  hyper- 
semic.  On  the  upper  and  right  side  of  the  hard  palate  and  very  near  where  it  joined 
the  soft  palate  Avere  two  small  yesicles  surrounded  by  distinct  red  areolse.  To  the  left 
and  below  these  lesions  were  three  minute  macules,  two  of  which  had  almost  become 
papules. 

This  case  illustrates  very  well  the  importance  of  making  a  thorough  examination 
of  the  throat  in  children,  for  unless  the  throat  had  been  examined  this  child  would 
have  been  supposed  to  have  had  a  cold  and  would  have  been  allowed  to  remain  in  the  clinic 
and  thus  spread  the  contagiura. 

The  following  case  illustrates  still  further  the  efflorescence  of  varicella 
when  at  its  height  and  on  the  second  day.  The  efflorescence  on  the 
back  is  sho^^Tl  in  Plate  XI. 

A  girl  was  attacked  with  headache  and  malaise  in  the  morning.  In  the  afternoon 
an  examination  showed  an  efflorescence  in  the  throat,  but  there  was  also  a  well-marked 


608 


PEDIATRICS. 


vesicular  efflorescence  on  the  back.  This  efflorescence  soon  began  to  come  out  in  crops 
in  difterent  parts  of  the  body,  on  the  limbs,  behind  the  eais,  and  on  the  scalp.  There 
were  also  a  few  lesions  on  the  face.  On  the  back  were  a  number  of  lesions,  some  of  which 
were  simply  macules,  and  again  a  few  of  the  macules  had  become  papules.     In  most 

Fig.  128. 


Varicella.    Stase  of  efflorescence,  third  dav. 


cases,  however,  the  lesions  were  distinctly  vesicular,  varying  in  their  contents  to  such  a 
degree  that  sometimes  they  had  a  pearly  white  appearance  and  again  the  yellowish 
color  of  a  vesicle  which  had  become  somewhat  pustular.  In  other  places  the  vesicles 
had  broken  down  and  little  crusts  had  formed  in  their  centres,  which  were  somewhat 
indented.  On  pricking  one  of  these  vesicles  it  collapsed  and  was  emptied  of  its  entire 
contents,  showing  that  it  was  unilocular.  The  vesicle  of  variola  when  pricked  in  this 
way  would  in  most  cases  be  only  partially  emptied,  showing  that  it  was  multilocular. 

The  lesions  of  varicella  are  well  represented  in  Fig.  128. 

This  child  was  brought  from  the  surgical  ward,  where  it  was  being  treated  with 
plaster-of-Paris  bandages  for  an  injury  to  the  arm.  The  efflorescence,  chiefly  vesicular 
in  character,  first  appeared  behind  the  ears.  The  whole  of  the  child's  back  was 
thickly  covered  with  the  efflorescence.  The  lesions  were  also  on  the  arms,  legs,  abdo- 
men, and  front  of  the  chest.  They  also  appeared  on  the  chin,  lips,  face,  nose,  fore- 
head, and  scalp. 

The  plaster  bandage  was  removed,  as  a  fixed  bandage  should  never  be  used  during 
the  course  of  any  of  the  eruptive  diseases,  owing  to  the  probability  that  extensive 
ulcerations  will  develop  under  them. 

The  following  case  and  chart  are  illustrative  of  gangrenous  varicella : 


SPECIFIC    INFECTIOUS    DISEASES. 


609 


A  child,  three  years  of  age,  was  brought  to  the  hospital  with  Pott's  disease,  and 
with  a  paraplegia  arising  from  a  transverse  myelitis  caused  by  the  disease.     Nothing 


CHART   27. 

Daj^s    of  Disease 

F 

1     1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

14 

15 

c 

107° 
105° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 

TEMP 

98° 
97° 
96° 
95° 

M  £ 

M   E 

M   E 

M  E 

M  E 

M  e'm  E 

M  r 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M   E 

M  K 

M  L 

M  E 

M   E 

41.6° 

41.1° 

40.5° 

40.0° 

39,4° 

38.8° 

38.3° 

37.7° 

37.2° 
37.0° 
36  6° 

36.1° 

35.5° 

35.0° 

1 

/V 

rO 

^ai 

7u 

\/ 

\ 

on 

/ 

V 

30 

Wzif 

/ 

J 

t 

^    / 

/ 

1    / 

J 

V 

u 

■J 

V 

v 

/ 

I, 

1/ 

V 

^/ 

\ 

/ 

V 

U/ 

'J. 

„v 

L 

P< 

llh 

5 

V 

■zn 

oe 

Uc 

Di 

se 

2S< 

3 



= 

Varicella  gangrenosa. 

abnormal  was  found  in  connection  with  the  lungs,  heart,  or  kidneys.  Until  the  child 
was  attacked  with  varicella  the  temperature  was  usually  normal,  but  sometimes  rose 
to  37.7°  C.  (100°  F.),  and  occasionally  as  high  as  38.3°  C.  (101°  F.). 

About  one  month  before  entering  the  hospital  the  child  became  restless,  and  his 
temperature  rose  somewhat.  On  the  following  day  the  symptoms  became  more 
marked,  and  the  temperature  was  found  in  the  evening  to  be  39.4°  C.  (103°  F.)  On 
this  day  an  efflorescence  of  varicella  appeared  on  his  skin.  During  the  third  day  of 
his  sickness  his  face  swelled,  and  in  the  evening  his  temperature  was  found  to  be 
41.1°  C.  (106°  F.).  The  vesicular  efflorescence  was  well  developed  on  his  trunk  and 
face  by  this  time.  Somewhat  later  it  became  universal  and  assumed  a  purulent  char- 
acter, especially  about  the  face.  During  the  fourth,  fifth,  and  sixth  days  of  the  dis- 
ease his  temperature  varied  in  the  evening  from  39°  C.  (102.2°  F.)  to  39.4°  C.  (103° 
F.).  On  the  seventh  day  of  the  disease  all  the  symptoms  increased  in  severity, 
and  the  temperature  was  found  to  be  41.1°  C.  (106°  F.)  On  this  day  some  of  the 
vesicles  on  the  face  had  become  ulcers.  Nothing  abnormal  was  found  in  the  lungs, 
and  no  albumin  or  casts  in  the  urine.  A  psoas  abscess  developed  during  the  progress 
of  the  varicella.  The  ulcers  on  the  face  extended  to  such  a  degree  that  the  child  lost 
the  sight  of  one  of  its  eyes.  The  child  sank  rapidly.  The  treatment,  which  was 
essentially  with  stimulants,  failed  to  keep  up  its  strength,  and  the  local  treatment  in 
connection  with  the  eye  proved  entirely  unsuccessful. 

The  child  continued  to  grow  weaker,  and  died  on  the  thirtieth  day  from  the  time 
when  the  first  symptoms  of  the  varicella  were  noticed."     No  autopsy  was  obtained. 


DIFFERENTIAL    DIAGNOSIS   OF    THE    EXANTHEMATA. 

The  characteristics  of  this  group  of  exanthemata  are  as  follows.  In 
none  of  these  diseases  has  the  specific  organism  been  determined.  When 
it  shall  have  been,  its  detection  will  enable  ns  to  state  definitely  what 

39 


61U 


PEDIATRICS. 


disease  we  have  to  deal  \vith,  and  even  in  the  atypical  cases  of  measles 
we  shall  be  able  to  decide  whether  it  is  a  case  of  true  measles  or 
some  disease  such  as  rubella,  which  closely  simulates  its  irregular  forms. 
The  following  table  presents  the  chief  points  of  differential  diagnosis  in 
the  exanthemata. 

TABLE  64. 


Scarlet  Fever. 


Measles. 


Incubation 4days-2  wks     10-12  days. 

Average -i  davs.  i    10  davs. 


Rubella. 


21-24  davs. 
21  davs. 


Variola. 


Varicella. 


8-20  days.  '  15-17  days. 
12  davs.    ,  17  davs. 


Prudroniata 


2  davs. 


3  daA-s. 


A  few  hours. 


3  davs. 


A  few  hours. 


Efflorescence 


Ervthema. 


Papules. 


Papules. 


Macules. 
Papules. 
Vesicles. 
Pustules. 


Vesicles. 


Desquamation  . .      Lamellar. 


Furfuraceous. 


Large  crusts. 


Small  crusts. 


Complications 
and  sequelae 


Kidney.         Eye. 
Ear.  Lung. 

Heart.  Tuberculosis 


Larynx. 
Lungs. 


In  addition  to  the  leading  points  which  are  indicated  in  the  table, 
the  general  symptoms,  the  topography,  and  the  temperature  of  these 
diseases  distinguish  them  from  each  other. 

The  slow  progressive  development  of  variola  is  ven,'  distinct  from  the 
acute,  rapid  course  of  all  the  others.  The  vomiting  and  sore  throat  of 
scarlet  fever  are  usually  quite  distinct  from  the  corj'za,  laclirj'mation,  and 
cough  of  measles.  In  variola  the  rise  of  temperature  during  the  pro- 
dromal stage,  its  decided  lessening  at  the  time  of  the  appearance  of  the 
efflorescence,  and  its  gradual  rise  again  during  the  stage  of  suppuration, 
are  very  distinct  from  the  sudden  rise  of  temperature  in  scarlet  fever 
-^during  the  prodromal  stage  and  up  to  the  height  of  the  efflorescence.  In 
like  manner  the  temperature  in  measles  differs  from  that  of  the  other 
diseases  in  its  sudden  rise  on  the  first  day  of  the  prodromal  stage,  in  its 
lessening  on  the  second  day,  and  in  its  rise  on  the  third  day  and  up  ta 
the  height  of  the  efflorescence.  The  manner  of  the  decline  of  the  tem- 
perature differs  in  variola,  in  scarlet  fever,  and  in  measles.  "While  in  variola 
it  is  slow  and  prolonged,  in  scarlet  fever  it  is  rather  rapid,  although  it 
declines  by  lysis,  and  in  measles  the  fall  is  often  by  crisis.  In  contradis- 
tinction to  variola,  scarlet  fever,  and  measles,  varicella  and  rubella  differ 
markedly  in  the  absence  of  a  prodromal  stage,  in  their  short  duration, 
and  in  their  evanescent  and  moderate  temperature.  In  the  atypical  forms 
of  the  exanthemata  it  may  be  impossible  to  distinguish  between  measles 
and  scarlet  fever,  or  between  measles  and  rubella. 


SPECIFIC   IXFECTIOUS    DISEASES.  qh 

PAROTITIS. 

Etiology. — Parotitis  (mumps)  is  a  liighly  infectious  disease  which 
attacks  the  parotid  gland.  Xo  specific  organism  has  been  determined. 
Its  period  of  incubation  is  usually  from  t^vo  to  three  weeks,  but  cases  in 
which  the  period  was  only  three  or  four  days  have  been  reported.  It  is 
exceedingly  rare  in  infancy,  but  Demme  has  reported  a  case  in  an  infant  of 
three  weeks.     It  is  most  common  between  the  ages  of  four  and  fourteen. 

Symptoms. — The  onset  of  the  attack  is  usually  accompanied  by  a 
sense  of  chilliness,  a  rise  of  temperature,  and  a  sensation  of  stiffness  and 
tenderness  about  the  jaws.  This  is  succeeded  by  a  swelling  in  the  region 
of  the  parotid  gland,  which  becomes  enlarged  and  tender,  rendering  deg- 
lutition difficult  and  often  very  pamful.  The  disease  begins  on  one  side, 
but  the  other  gland  is  usually  involved  in  a  day  or  two.  The  infection  is 
sometimes  confined  to  the  submaxillary  glands  on  one  or  both  sides. 

The  duration  of  an  attack  of  parotitis  is  from  a  few  days  to  a  week, 
but  the  infection  may  last  for  two  or  three  weeks,  and  it  has  been  stated 
in  some  cases  to  antedate  the  appearance  of  the  glandular  enlargement. 
In  boys  at  the  age  of  puberty  the  complication  of  orchitis  at  times  arises. 

Although  the  symptoms  of  parotitis  are  commonly  very  mild,  un- 
usual cases  sometimes  occur  in  which  the  children  are  cjuite  sick,  and 
there  have  been  instances  in  which  the  orchitis  was  of  so  high  a  grade 
that  acute  delirium  super^'ened,  and  in  one  case  reported  by  Dukes  the 
boy  fainted  when  the  orchitis  began.  Exceptionally,  some  cases  of  paro- 
titis are  marked  by  general  malaise  with  little  or  no  pain.  Nephritis, 
facial  paralysis,  deafness  of  sudden  onset  and  permanent,  suppuration  of 
the  parotid  gland,  pneumonia,  endocarditis,  pericarditis,  and  meningitis 
are  rare  complications  or  sequelEe  of  mumps. 

Diagnosis. — It  is  sometimes  difficult  to  differentiate  parotitis  froui  a 
simple  non-infectious  enlargement  of  the  parotid  gland  or  of  the  glands 
in  its  neighborhood.  "When  the  parotid  gland  is  enlarged  it  usually  shows 
a  characteristic  swelling  under  and  behind  the  lobe  of  the  ear.  so  that  the 
lobe  is  pushed  somewhat  upward  and  forAvard.  This  swelling  increases 
rapidly,  is  ven'  tender,  is  not  especially  reddened,  does  not  fluctuate,  and 
is  accompanied  by  constitutional  symptoms.  The  diagnosis  is  readily 
made  if  after  a  few  days  the  unilateral  swelling  is  followed  by  corre- 
sponding symptoms  on  the  opposite  side. 

Treatment. — There  is  no  especial  treatment  for  the  disease,  as  it  is 
self-limited  and  runs  a  definite  course.  The  children  should  be  carefuhy 
isolated,  in  order  that  there  may  be  no  further  spread  of  the  affection. 
If  the  isolation  is  to  be  continued  until  all  danger  of  infection  has  passed, 
it  should  be  maintained  in  ordinary  cases  for  three  weeks  from  the  onset, 
or,  in  prolonged  cases,  until  ten  days  or  two  weeks  after  the  disappear- 
ance of  the  swelling,  ils  deglutition  is  painful,  the  chet  is  usually  milk 
and  soups.     The  patients  should  be  carefully  protected  fi'om  exposure, 


612 


PEDIATRICS. 


Fig.  129. 


and  should  be  Lonfined  to  their  rooms.  Older  children  should  be  con- 
fined to  bed,  as  orchitis  in  boys  and  trouble  with  the  mammae  in  adoles- 
cent girls  are  less  likely  to  arise  under  these  conditions.  It  is  usually 
better  to  apply  some  soft  cotton-wool  to  the  painful  swelling,  and  to  protect 
it  from  any  irritation. 

Submaxillary  Mumps. — The  submaxillary  glands  are  enlarged  in 
children  from  various  causes.  At  times  the  enlargement  of  the  glands  is 
accompanied  by  pain  and  tenderness,  constituting  a  disease  which  has  been 
called  submaxillary  mumps.    In  the  beginning,  however,  we  should  not  at 

once  make  this  diagnosis,  as  the  glands 
may  become  enlarged  and  tender  from 
various  causes  which  have  no  connec- 
tion with  the  specific  disease  mumps. 

Fig.  129  represents  a  probable  case 
of  submaxillary  mumps. 

The  child,  a  girl  two  years  and  four 
months  old,  was  suddenly  attacked  with  a 
swelling  of  the  suhmaxillary  glands,  accom- 
panied by  pain  and  a  slight  amount  of  tender- 
ness over  the  swollen  region.  She  had  a  his- 
tory of  exposure  to  parotitis.  On  the  follow- 
ing day  the  swelling  had  extended  under  the 
entire  chin  and  up  the  left  side  of  the  neck 
to  the  face  and  ear. 

The  swelling,  pain,  and  tenderness  lasted 
for  a  number  of  days  and  then  gradually  sub- 
sided.    Nothing  more  definite  was  discovered 
regarding  the  case. 
The  diagnosis  in  a  case  of  this  kind  must  be  held  in  abeyance  for  a. few  days,  and 

strict  isolation  should  be  enforced,  as,  if  the  cause  of  the  glandular  enlargement  proves 

to  be  infectious,  other  children  should  be  protected. 


Submaxillary  mumj*, 


DIVISION    IX. 

DISEASES   OF   THE   MOUTH,    NOSE,    EAR,    NASO- 
PHARYNX,  AND    PHARYNX. 


DISEASES  OF  THE  MOUTH. 

NoME^■cLATURE. — Mucli  confusioii  exists  as  to  the  nomenclature  of  dis- 
eases of  the  mouth.  A  great  variety  of  names  has  been  used  by  different 
authors  to  describe  the  same  disease,  so  that  at  times  it  is  c{uite  difficult 
for  one  investigator  to  compare  his  work  with  that  of  another.  Such 
terms  as  "canker"  and  "aphthae"  are  so  commonly  used  for  almost  any 
morbid  condition  of  the  mucous  membrane  of  the  mouth  that  they  have 
ceased  to  convey  any  definite  idea. 

Diseases  of  the  mouth  occur  more  frequently  and  in  much  greater 
variety  in  infancy  and  in  early  childhood  than  at  any  later  period  of  life. 
This  depends  parity  on  the  anatomical  conditions  at  different  periods  of 
development  and  partly  on  the  external  influences  which  are  brought  to 
bear  upon  the  buccal  mucous  membrane.  During  the  first  three  or  four 
months  of  life  the  function  of  the  salivary  glands  is  not  developed,  and 
the  flow  of  saliva  is  insignificant.  This  lack  of  saliva  allows  the  mucous 
membrane  of  the  mouth  to  be  dry  in  comparison  with  that  of  the  older 
subject.  Even  after  the  saliva  is  secreted  the  infant  is  more  apt  under 
certain  conditions  to  let  it  flow  from  the  mouth  than  to  swallow  it.  so 
that  the  mucous  membrane  of  the  lips  and  mouth  may  present  a  different 
appearance  in  young  infants,  when  they  are  attacked  by  various  morbid 
processes,  from  that  seen  at  a  later  period  of  development.  We  must 
also  remember  that  the  salivarj"  glands  in  addition  to  their  especial  func- 
tion are  excretory  organs,  and  that  substances  which  are  absorbed  by  the 
stomach  may  be  eliminated  by  the  mouth  and  in  this  way  become  sources 
of  irritation  and  disease  in  the  latter.  The  mucous  membrane  of  the 
mouth  during  almost  the  whole  period  of  infancy  is  subject  to  external 
sources  of  irritation  to  which  older  children,  as  a  rule,  are  not  liable. 
Thus,  during  the  first  year  the  mucous  membrane  is  subjected  to  more  or 
less  mechanical  irritation  througli  the  mechanism  of  sucking.  At  this 
period,  also  it  is  very  common  for  foreign  organisms  to  be  introduced  into 
the  mouth  by  means  of  the  fingers  cither  of  the  infant  itself  or  of  its  at- 
tendant. It  is  not  surprising,  therefore,  that  we  should  meet  with  a  great 
variety  of  pathological  conditions  in  the  mouth  in  infancy. 

613 


614 


PEDIATRICS. 


The  organisms  which  occur  in  the  mouth  are  so  numerous  that  very 
few  of  them  have  as  yet  been  differentiated  in  such  a  way  that  they  can 
be  known  as  tlie  cause  of  tlie  specific  disease  in  whicli  they  are  often 
found.  We  cannot,  therefore,  at  the  present  time  describe  the  various 
diseases  of  the  moutli  under  their  proper  etiological  headings,  and  we  are 
forced  to  adopt  provisionally  the  name  of  the  pathological  lesion  which 
exists  in  them. 

In  almost  every  disease  of  the  mouth  which  occurs  in  infants  and  in 
young  ciiildren  there  is  a  coexisting  inflammation  of  the  mucous  mem- 
brane. This  inflammation  may  at  times  be  very  mild  and  often  difficult 
to  detect  as  such,  but  it  still  presents  a  recognizable  pathological  condi- 
tion. This  inflammatory  condition,  although  not  necessarily  preceding  the 
various  diseases,  yet  in  a  large  number  of  cases  either  exists  as  a  basis  on 
which  the  disease  develops,  or  so  closely  accompanies  it  that  the  general 
name  stomatitis  (inflammation  of  the  mucous  membrane  of  the  mouth) 
seems  to  be  a  proper  term  to  use  in  connection  with  all  these  diseases. 

Under  the  general  heading  stomatitis  we  can  speak  of  most  of  the 
important  diseases  which  affect  the  mucous  membrane  of  the  mouth  in 
infancy  and  early  childhood.  These  diseases  may  be  divided  into  four 
general  headings,  according  to  the  character  of  the  lesions  which  occur  in 
them. 

The  following  table  represents  the  provisional  nomenclature  of  dis- 
eases of  the  mouth  adopted  by  the  American  Pediatric  Society.  Although 
its  basis  is  in  part  pathological  and  in  part  etiological,  it  offers  a  very  con- 
venient classiflcation  of  the  types  of  stomatitis  one  meets  with  clinically. 
We  are  much  indebted  to  Forchheimer  for  his  valuable  work  on  this 
subject : 

TABLE  65. 

f  Simplex. 


Stomatitis  . 


Catarrhalis. 


-T'       ^v        i^-  f  Secondary  to  the 

J  Lxanthematica J  •' 

I       Exanthemata. 


Traumatica. 

Herpetica Aphthosa. 

Scorbutu.?. 


Ulcerosa. 


f  Mechanical. 
\  Thermal. 
[  Chemical. 


f  Arsenic. 
Mineral  Poisons .i  Lead. 

'■  And  other  diseases. 


(  Hvphomycetica Thrush. 

j  [■  Diphtheria 

Mycetogenetica \  -r,       i    -,  r      v 

"'        °  i  rseudo-MemDranosa 


Tuberculosis. 
Syphilis, 
and  like  diseases. 
GangrEenosa Noma 


DISEASES   OF   THE    MOUTH.  615 

In  accordance  with  this  table  the  four  general  names  which  cover  all 
these  diseases  are  stomatitis  catarrhalis,  stomatitis  herpetica,  stomatitis  ulcer- 
osa, and  stomatitis  mycetogenetica. 

STOMATITIS  CATARRHALIS. 

Stomatitis  Simplex. — The  form  of  stomatitis  catarrhalis  which  is 
called  the  simple  or  erythematous  form  is  commonly  seen  in  young  infants 
as  a  hyperaemic  condition  of  the  blood-vessels,  causing  diffuse  redness  of 
the  whole  buccal  mucous  membrane.  This  erythematous  form  is  so 
common  and  so  entirely  without  clinical  significance  that  it  may  be  con- 
sidered as  physiological  and  need  only  be  referred  to. 

Stomatitis  Exanthematica. — The  second  form,  which  is  called  ex~ 
anthematica,  is  the  condition  of  the  mucous  membrane  which  occurs 
secondarily  to  the  exanthemata,  and  has  already  been  described  in  con- 
nection with  these  diseases.     It  therefore  need  not  be  spoken  of  ag-ain. 

Stomatitis  Traumatica. — The  third  form,  which  is  called  traumatica, 
is  the  one  which  represents  the  characteristic  stomatitis  catarrhalis.  The 
causes  of  the  traumatic  form  of  stomatitis  catarrhalis  are  very  numerous. 
They  may  be  mechanical,  thermal,  or  chemical. 

Mechanical. — ^Among  the  most  common  mechanical  causes  may  be 
cited  the  irritation  produced  by  rubber  nipples,  too  vigorous  cleansing  of 
the  mouth,  injudicious  rubbing  of  the  gums  during  dentition,  and  local 
irritation  from  a  tooth. 

Thermal. — The  thermal  form  of  traumatism  may  result  from  the  admin- 
istration of  food  which  is  too  hot. 

Chemical. — The  chemical  irritation  may  arise  in  various  ways,  as  from 
lack  of  cleanliness  in  the  mouth,  with  its  resulting  fermentation,  and  from 
the  elimination  of  irritating  products  from  the  glands  apparently  con- 
nected m  some  way  with  disturbance  in  the  gastro-enteric  tract. 

It  is  probable  also  that  various  forms  of  bacteria  or  their  products 
may  cause  both  mechanical  and  chemical  irritation  of  the  buccal  mucous 
membrane.  Our  knowledge  of  the  bacteriology  of  the  mouth  is  as  yet, 
however,  so  limited  that  we  can  scarcely  undertake  to  describe  the  relation 
between  special  forms  of  bacteria  and  special  lesions  of  the  mucous 
membrane. 

Pathology,  Anatomy,  and  Symptoms. — As  the  lesions  which  are  seen  in 
the  mouth  of  an  infant  with  stomatitis  catarrhalis  during  life  almost  en- 
tirely disappear  at  death,  and  as  very  few  post-mortem  examinations  have 
been  made  of  these  lesions,  we  can  speak  of  the  pathological  anatomy 
and  symptoms  of  this  disease  together. 

The  lesion  is  essentially  an  inflammatory  one,  and  occurs  in  different 
grades.  On  examining  the  mucous  membrane  in  these  cases  it  is  seen 
that  the  entire  lining  of  the  mouth  is  intensely  reddened,  that  the  tem- 
perature of  the  mouth  is  increased,  that  there  is  usually  a  certain  amount 
of  swelling,  and  that,  although  the  mucous  membrane  may  be  dry  under 


gig  I'tlJlATKlCS. 

certain  circumstances,  especially  at  first,  yet,  as  a  rule,  there  is  later 
a  hypersecretion  of  mucus  and  saliva.  The  blbod-vessels  are  so  dis- 
tended and  their  walls  so  weak  that  the  slightest  traumatism  may  cause 
their  rupture,  and  the  saliva  is"  frequently  mixed  with  a  little  blood.  lu 
older  children  the  mucous  membrane  may  be  considerably  swollen,  espe- 
cially behind  the  incisor  teeth.  In  addition  lo  this  general  condition  of 
the  mucous  membrane  of  the  mouth,  at  times  the  lips  are  found  to  be 
swollen  and  much  reddened.  The  surface  of  the  mucous  membrane 
shows  a  number  of  small  round  prominences,  which  are  the  muciparous 
folHcles.  If  complete  occlusion  of  the  ducts  of  these  follicles  occurs,  great 
dilatation  of  the  gland  will  take  place,  and  a  cyst  may  be  formed.  This, 
however,  is  a  comparatively  rare  complication.  In  connection  with  the 
disturbance  of  the  glands  in  the  mouth  the  lymphatic  glands  are  usually 
involved  secondarily. 

When  the  catarrhal  condition  is  at  its  height  the  mucous  membrane  is 
so  vulnerable  that  even  slight  traumatisms  may  cause  abrasions.  The 
most  marked  symptom  of  stomatitis  is  pain.  The  infant  is  restless, 
usually  has  a  heightened  temperature,  and  refuses  to  take  its  nourish- 
ment. The  saliva  is  acid  in  its  reaction,  and  Avhen  secreted  in  large 
quantities  flows  out  of  the  mouth  upon  the  chin  and  neck,  sometimes 
causing  considerable  irritation.  The  tongue  is  dry  and  white  at  first,  then 
becomes  of  a  grayish  color,  and  as  the  secretion  of  saliva  increases  the 
coating  of  the  tongue  is  washed  off  and  its  surface  becomes  red. 

Prognosis. — The  prognosis  of  stomatitis  catarrhalis  is,  as  a  rule,  good. 
Although  the  disease  does  not  run  a  definite  course,  yet  in  most  cases 
after  a  few  days  the  pathological  condition  improves  and  the  symptoms 
grow  less  severe.  The  course  of  the  disease  is,  however,  often  lengthened 
by  the  secondary  conditions  which  arise  from  the  gastric  disturbances, 
which  may  be  caused  by  swallowing  the  irritating  secretions  of  the  mouth. 
In  weak,  poorly  nourished  infants  who  refuse  to  nurse  or  to  take  the  food 
which  is  given  them,  serious  results  may  arise  from  a  lack  of  sufficient 
"nourishment,  so  that  in  these  cases  the  prognosis  is  always  grave.  In 
older  children  the  prognosis  is  very  good. 

Treatment. — Although  stomatitis  catarrhalis  may  run  a  favorable 
course  without  any  treatment  whatever,  yet  there  are  so  many  causes 
which  may  prolong  its  course  or  give  rise  to  secondary  affections  that  it 
is  exceednigly  miportant  to  treat  the  disease  at  once.  The  indications 
for  treatment  are  to  relieve  the  pam  and  to  allay  the  irritation  of  the 
mucous  membrane  so  that  a  sufficient  amount  of  nourishment  may  be 
taken  by  the  infant  to  prevent  it  from  being  harmed  by  a  lack  of  nourish- 
ment or  by  a  secondarj^  disturbance  of  the  gastro-enteric  tract.  If  the 
cause  can  be  ascertained,  it  should  be  removed  at  once.  The  local  appli- 
cation of  a  one  to  two  per  cent,  cold  solution  of  bicarbonate  or  borate  of 
sodium  in  distilled  water  is  indicated.  This  solution  should  be  used  very 
gently  every  half-hour  when  the  infant  is  awake,  by  means  of  a  dropper, 


DISEASES    UF    THE    MUUTH.  617 

and  occasionally  on  a  clean  swab  of  absorbent  cotton.  The  infant  should 
be  systematically  fed  at  regular  intervals,  whether  it  resists  or  not;  and 
if  it  is  not  being  nursed  or  will  not  suck  from  the  nipple,  a  carefully 
modified  milk  at  a  temperature  of  about  32.2°  C.  (90°  F.)  should  be  ad- 
ministered with  a  spoon  or  dropper.  There  is  no  necessity  for  giving  any 
drug  internally  in  this  disease. 

When  the  stomatitis  proves  to  be  intractable  and  lasts  for  more  than 
three  or  four  days,  the  mouth  can  be  gently  touched  with  a  cotton  swab 
wet  with  a  one  per  cent,  solution  of  nitrate  of  silver.  This  should  be 
done  once  a  day,  and  the  mouth  washed  carefully  with  cold  sterilized 
water  after  the  application. 

When  there  are  any  abrasions  Avhich  show  a  tendency  to  extend  or  to 
form  an  ulcer,  they  should  be  touched  with  a  little  nitrate  of  silver  melted 
on  the  end  of  a  silver  probe.  These  abrasions  are  often  so  painful  that  in 
themselves  they  may  prevent  the  child  from  taking  its  food,  and  after  they 
have  been  treated  with  the  nitrate  of  silver  the  child  will  often  again  take  its 
nourishment  readily.     The  following  case  represents  stomatitis  catarrhalis  : 

An  infant,  six  months  old,  was  reported  to  liave  been  always  healthy,  and  to  have 
been  nursed  by  its  mother.  It  cut  its  first  tooth,  a  middle  lower  incisor,  when  it  was 
five  months  old.  Nothing  abnormal  was  noticed  about  the  infant  until  it  became  fret- 
ful, restless,  had  a  heightened  temperature  of  about  38.8°  C.  (102°  F.),  and  vomited 
occasionally.  Although  it  did  not  cry  a  great  deal,  it  frequently  whimpered,  as  though 
in  pain,  and  kept  putting  its  fingers  to  its  mouth.  A  few  days  later  it  refused  to  nurse. 
When  it  was  put  to  the  breast  it  appeared  to  be  hungry  and  would  take  hold  of  the 
nipple  vigorously,  but  immediately  afterwards  would  draw  its  head  away,  as  though 
sucking  the  nipple  caused  pain. 

A  physical  examination  showed  nothing  abnormal  except  in  the  mouth.  The 
mucous  membrane  of  the  mouth,  tongue,  and  gums  was  reddened,  and  small  raised 
spots  were  seen  corresponding  to  the  positions  of  the  muciparous  glands.  The  mucous 
membrane  of  the  tongue  and  lips  was  somewdiat  swollen  and  hot,  and  evidently  sensi- 
tive to  the  touch.  Where  the  tooth  touched  the  tongue  the  inflammatory  condition  was 
especially  marked,  and  it  was  possible  that  the  sharp  edge  of  the  tooth  was  the  original 
starting-point  of  the  general  inflammation. 

In  the  above  ease  the  indications  were  for  active  treatment,  as  the  infant 
was  losing  in  weight  from  lack  of  sufficient  nourishment.  When  the 
mouth  is  in  this  condition  there  is  also  a  great  liability  to  other  diseases 
being  implanted  upon  it,  as  the  mucous  membrane  is  very  vulnerable  when 
a  pronounced  stomatitis  catarrhalis  is  present.  The  saliva  flows  from  the 
mouth  in  such  quantities  and  is  so  irritating  that  an  eczematous  condition 
is  likely  to  be  produced  on  the  chin.  The  following  prescription  will  be 
found  useful  in  such  cases  : 

Prescriptiox  43. 
Metric.  Apothecary. 


Gramma. 

R   Sodii  boratis 1 

Glycerini 7 

Aq.  destil.    ad  120 


8  R   Sodii  boratis gr.  xxx  ; 

5  Glycerini ,5  ii  ,• 

00  Aq.  destil ad  5  iv. 


M.  M. 


618  PEDIATRICS. 

This  should  be  applied  every  hour  while  the  child  is  awake.  The 
dim  should  frequently  be  dried  gently  and  a  little  vaseline  applied  if  there 
is  any  eczema.  If  the  infant  is  unwilling  to  nurse  because  of  the  stoma- 
titis, the  milk  should  be  given  by  means  of  a  dropper  regularly  every  two 
hours  until  it  will  again  take  the  breast.  Improvement  should  be  ex- 
pected within  four  or  five  days. 

STOMATITIS   HERPETIOA. 

The  name  herpetica  has  been  adopted  for  the  next  form  of  stomatitis, 
because  it  seems  to  represent  most  nearly  the  lesion  which  is  seen  on  the 
mucous  membrane,  although  it  is  not  definitely  settled  that  it  is  a  true 
herpes. 

The  disease  consists  of  a  catarrhal  stomatitis  in  the  course  of  which 
certain  lesions  resembUng  sub-epithehal  vesicles  surrounded  by  areolae 
occur  irregularly  and  in  different  parts  of  the  entire  buccal  cavity.  This 
form  of  stomatitis  has  usually  been  known  as  stomatitis  aphthosa  {d(pda,  an 
eruption  or  ulceration).  This  name  was  given  to  it  by  Bohn  as  distinctive 
from  the  other  forms  of  stomatitis,  but  it  does  not  represent  the  affection 
especially  well. 

Etiology. — As  a  rule,  when  the  mucous  membrane  of  the  infant's 
mouth  is  in  a  normal  condition  it  is  not  readily  affected  by  the  various 
irritants  which  produce  its  special  diseases.  When  a  catarrhal  condition 
is  present  the  mucous  membrane  becomes  more  vulnerable  and  the  various 
diseases  have  an  opportunity  to  develop.  This  apparently  is  illustrated 
in  the  case  of  stomatitis  herpetica,  in  conjunction  with  which  affection  a 
catarrhal  stomatitis  is  always  found.  No  cause,  either  local  or  general, 
has  as  yet  been  determined  for  this  disease.  Various  micro-organisms 
have  been  observed  in  the  mouth  when  it  is  affected  by  stomatitis  her- 
petica, but  no  actual  connection  has  been  discovered  between  them  and 
the  disease.  This  affection  may  be  found  associated  with  a  number  of 
other  diseases,  but  usually  occurs  alone.  It  does  not  seem  to  be  con- 
tagious, nor  to  be  especially  connected  with  diseases  of  the  gastro-enteric 
tract  or  with  dentition,  although  it  very  commonly  occurs  during  the 
dental  period.  It  appears  to  be  the  result  of  certain  deleterious  influences 
which  act  upon  the  nerve-centres  and  produce  an  herpetic  efflorescence 
on  the  mucous  membrane  which  corresponds  closely  to  that  which  is 
seen  in  herpes  on  the  skin. 

Pathological  Anatomy  and  Symptoms. — In  addition  to  the  usual  lesions 
of  a  stomatitis  catarrhalis,  spots,  not  necessarily  symmetrical  or  unilateral, 
of  different  sizes  and  of  different  shades  of  white  or  grayish  white,  appear 
in  various  parts  of  the  mouth,  especially  on  the  inner  surface  of  the  lip,  on 
the  side  and  under  surface  of  the  tongue,  and  on  the  gums.  These  lesions 
do  not  affect  the  follicles  of  the  mouth,  and  the  efflorescence  cannot  be 
called  follicular,  as  it  is  closely  connected  with  the  muciparous  glands. 
The  lesions  make  their  appearance  with  great  rapidity,  and  develop  very 


PLATE   XII. 


Thiuih. 


Varicella, 


Stomaiitis  heiijeiica. 
(Aphthosa.) 


Stomatitis  ulcerosa. 
( Scorbutus. ) 


Follicular  tonsillitis 


Diphtheria. 


DISEASES   OF    THE    MOUTH.  019 

quickly  from  a  macule  into  what  is  supposed  to  be  a  vesicle.  The  action 
of  the  secretions  of  the  mouth  upon  these  lesions  necessarily  prevents 
them  from  having  the  same  definite  appearance  that  they  would  present 
on  the  skin.  The  course  of  the  disease  so  strongly  simulates  that  of 
herpes  that  at  present  it  would  seem  wise  to  consider  the  efflorescence 
herpetic. 

The  general  appearance  of  the  efflorescence  when  at  its  height  is  that 
of  a  sub-epithelial  vesicle,  somewhat  glistening,  of  a  whitish-gray  color, 
and  surrounded  by  a  red  areola.  The  lesions  may  be  only  a  few  in 
number,  scattered  irregularly  over  the  parts  of  the  mucous  membrane 
which  we  have  already  described.  At  times,  however,  the  efflorescence  is 
very  diffuse,  sometimes  appearing  as  minute  grayish  points,  which  may 
become  much  larger  and  cover  the  mucous  membrane  so  thickly  as 
almost  to  simulate  a  false  membrane.  In  a  still  later  stage  of  the  disease 
these  lesions  may  break  down  and  form  small  superficial  ulcers. 

An  infant  or  young  child  affected  by  stomatitis  herpetica  presents  a 
very  characteristic  appearance.  It  looks  dull  and  apathetic,  and  wishes 
to  lie  quietly  in  bed.  It  usually  has  a  heightened  temperature,  and  evi- 
dently suffers  from  pain  and  heat  in  its  mouth.  The  saliva  flows  from 
the  mouth  in  large  quantities,  and  often  irritates  the  chin  and  neck  to  such 
an  extent  that  an  eczematous  condition  results.  The  child  refuses  to  take 
its  nourishment,  and  is  very  fretful  and  restless.  These  symptoms  con- 
tinue for  four  or  five  days  or  a  week,  and  sometimes  extend  over  a  period 
of  two  weeks,  the  disease  then  disappearing  of  itself;  in  fact,  it  appears 
to  be  self-limited.  Unless  the  lesions  of  stomatitis  herpetica  are  compli- 
cated by  those  of  stomatitis  ulcerosa,  the  saliva  is  never  fetid. 

Prognosis. — The  prognosis  of  stomatitis  herpetica  is  very  favorable, 
although  infection  from  other  diseases  may  take  place.  This  latter  occur- 
rence is,  however,  exceedingly  rare.  Relapses  are  very  uncommon  in 
this  form  of  stomatitis,  and  the  lesions  usually  heal  readily. 

Treatment. — There  is  no  internal  treatment  which  is  of  certain  benefit 
in  this  disease.  The  indications  for  treatment  are  to  allay  the  irritation  of 
the  mucous  membrane  and  to  prevent  its  infection  by  some  other  poison. 
The  mouth  in  general  should  be  treated  as  has  just  been  recommended 
in  the  case  of  stomatitis  catarrhalis.  As  a  rule,  very  little  treatment  is 
necessary  beyond  occasionally  cleansing  the  mouth  with  the  solution 
(Prescription  43,  page  617)  already  mentioned.  The  ulcers  which  do  not 
heal  readily  can  be  touched  with  nitrate  of  silver.  The  feeding  should  be 
at  regular  intervals  and  if  necessary  forced. 

Plate  XII.,  facing  page  618,  represents  stomatitis  herpetica  in  a  boy  four  years 
old.  He  was  perfectly  well  until  two  days  previous  to  the  appearance  shown  in  the 
plate  ;  he  then  began  to  be  feverish,  was  restless  at  night,  refused  to  take  his  food, 
and  seemed  quite  sick.  On  the  following  day  the  entire  mucous  membrane  of  the 
mouth  was  found  to  be  affected  with  stomatitis  catarrhalis,  and  somewhat  later  the 
herpetic  form  of  stomatitis,  the  lesions  of  which  are  shown  in  the  plate. 


(;2()  PEDIATRICS 

On  drawing  down  the  lower  lip  on  the  right  side  a  number  of  small  grayish-white 
spots  surrounded  by  a  somewhat  deeper,  reddened  mucous  membrane  were  seen.  At 
a  little  distance  from  them,  on  the  left  side  of  the  lip,  close  to  the  gum,  was  appar- 
ently a  sub-epithelial  vesicle.  On  the  inner  side  of  the  lower  gum  one  of  these  vesicles 
had  broken  down,  and  a  small  superficial  ulcer  covered  with  a  grayish-white  exudation 
was  seen.  There  were  also  lesions  of  the  same  vesicular  character  along  the  left  edge 
of  the  tongue.  The  entire  mucous  membrane  of  the  mouth  was  intensely  reddened, 
and  the  case  illustrated  stomatitis  catarrhalis  as  well  as  stomatitis  herpetica. 

The  child  absolutely  refused  to  take  food,  and  so  it  had  to  be  forced  upon  him. 
In  a  few  days  the  more  severe  stage  of  the  disease  passed  away  and  he  took  his  food, 
The  treatment  was  to  bathe  the  inflamed  mucous  membrane  with  cold  sterilized  Avater, 
and  small  quantities  of  an  alkaline  modified  milk  were  given  to  him.  As  this  child 
appeared  lying  with  his  eyes  half  closed,  with  flushed  cheeks,  in  an  apathetic  con- 
dition, occasionally  whimpering  as  if  in  pain,  and  with  the  saliva  flowing  contin- 
uously from  his  mouth  on  the  pillow,  one  could  readily  diagnosticate  the  disease 
stomatitis.  When,  in  addition,  the  characteristic  lesions  of  the  mucous  membrane 
irregularly  distributed  throughout  the  buccal  cavity  are  noticed,  and  no  evidence  of  a 
membranous  exudation  can  be  found,  there  need  be  no  doubt  as  to  the  diagnosis.  In- 
ternal remedies  are  not  needed  in  a  case  of  this  kind.  Chlorate  of  potassium,  which 
is  so  commonly  used  in  all  diseases  of  the  mouth,  is  not  indicated  in  the  forms  of 
stomatitis  which  have  just  been  described. 

In  connection  with  tliis  form  of  stomatitis  may  be  mentioned  certain 
lesions  occurring  in  the  mouths  of  new-born  infants  which  have  been 
called  Bednar''s  aphthce.  These  lesions  consist  of  small  superficial  ulcers 
usually  having  a  grayish  coating,  and  appearing  on  the  posterior  part  of 
the  hard  palate  and  on  the  soft  palate.  They  are  now  supposed  not  to 
represent  a  specific  disease,  but  to  be  the  result  of  traumatism,  such  as 
may  arise  from  a  badly-shaped  rubber  nipple  or  from  undue  violence  in 
washing  the  mouth. 

They  are  to  be  treated  as  any  local  irritations  of  the  mouth  should 
be, — namely,  by  removing  the  cause,  applying  a  solution  of  bicarbonate 
of  sodium,  and,  if  necessary,  touching  them  with  nitrate  of  silver. 

STOMATITIS    ULCEROSA. 

By  stomatitis  ulcerosa  we  mean  a  peculiar  pathological  process  of  the 
mucous  membrane  of  the  mouth  occurring  only  when  there  are  teeth 
and  affecting  the  gums  around  the  teeth. 

Etiology. — This  affection  of  the  mouth  may  occur  in  the  course  of  a 
number  of  diseases,  notably  in  scorbutus.  It  may  also  be  produced  by 
the  internal  administration  of  such  mineral  poisons  as  arsenic,  lead,  or 
mercury.  Occasionally  it  may  occur  as  a  local  affection  without  known 
cause,  but  it  is  probably  produced  by  the  irritation  of  some  form  of  micro- 
organism not  yet  determined,  although  the  pyogenic  bacteria  are  very 
commonly  present. 

The  most  common  form  of  stomatitis  ulcerosa  produced  by  the  mineral 
poisons  is  that  which  is  seen  in  connection  with  mercurial  salivation. 

As  in  the  other  forms  of  stomatitis,  it  is  probable  that  the  mucous 
membrane  is  first  affected  by  a  catarrhal  process  which  renders  it  vul- 


DISEASES   OF   THE    MOUTH.  621 

nerable  to  the  special  irritation  which  produces  stomatitis  ulcerosa.  This 
preceding  stomatitis  catarrhalis  may  be  produced  directly  by  local  irri- 
tation in  the  mouth  itself,  or  may  be  the  result  of  some  disturbance  of 
the  general  system.  For  this  reason  stomatitis  ulcerosa,  as  a  rule,  does 
not  affect  primarily  a  healthy  individual.  Thus  a  poorly  nourished  child, 
and  one  whose  mouth  is  not  properly  cared  for,  will  be  more  apt  to  have 
this  disease  develop  than  one  who  is  correctly  fed  and  whose  mouth  is 
clean. 

Pathological  Anatomy. — The  pathological  condition  is  one  of  necro- 
biosis ;  that  is,  there  is  softening  as  well  as  death  of  the  tissues.  The 
disease,  although  starting  in  the  mucous  membrane,  may  extend  to  the  peri- 
osteum, and  even  produce  necrosis  of  the  bone.  It  begins  at  the  free  border 
of  the  gums,  and  can  extend  in  all  directions,  but  it  never  passes  beyond 
the  mucous  membrane  of  the  mouth.  The  softening  of  the  tissue  not  only 
changes  its  consistency  but  also  renders  it  more  movable,  and  in  this  way 
the  gums  at  times  become  so  swollen  and  loosened  that  they  may  entirely 
cover  the  teeth. 

Symptoms. — Stomatitis  ulcerosa  is  usually  preceded  by  moderate  consti- 
tutional symptoms,  such  as  fever,  loss  of  appetite,  and  frelfulness.  The 
mucous  membrane  of  the  gums  at  the  free  margin  of  the  teeth  becomes 
reddened  and  soon  begins  to  swell.  The  normal  curve  of  the  gum  be- 
comes almost  a  straight  line  and  covers  the  lower  part  of  the  teeth.  The 
gums  in  the  space  between  the  teeth  remain  unaltered  at  first.  The 
mucous  membrane  then  begins  to  change  in  color  and  becomes  purplish. 
Extreme  congestion  and  softening  of  the  tissues  allow  hemorrhage  to 
take  place  from  the  slightest  pressure.  Although  the  anterior  surface  of 
the  gums  is  most  commonly  affected,  yet  in  severe  cases  the  posterior 
surface  is  also  involved.  As  the  process  develops  further  the  gum  be- 
comes more  and  more  loosened  as  it  extends  over  the  teeth.  A  muco- 
purulent secretion  collects  between  the  gums  and  the  teeth  and  causes  a 
fetid  odor.  According  to  Forchheimer,  a  yellowish  seam  then  appears  at 
the  top  of  the  swollen  outline  of  the  gum.  This  is  due  to  the  molecular 
destruction  which  has  already  begun.  This  seam  is  at  first  very  narrow, 
but  later  it  may  become  broader  and  involve  almost  the  whole  of  the 
gum.  In  connection  with  this  characteristic  appearance  of  the  gums 
there  is  a  great  hypersecretion  of  saliva.  At  the  height  of  the  disease  the 
child  evidently  suffers  from  pain  in  the  mouth,  cries  a  great  deal,  and 
rapidly  emaciates.  The  lymphatic  glands  are  usually  swollen,  and  remain 
so  until  the  disease  has  ended.  When  the  yellowish  material  which  con- 
stitutes the  seam  already  referred  to  is  removed,  an  ulcerated  surface  will 
be  found  beneath.  Although  stomatitis  ulcerosa  may  begin  about  any  of 
the  teeth,  its  most  common  starting-point  is  around  the  lower  incisors. 
As  the  disease  improves,  the  gums  gradually  become  less  swollen  and 
congested,  returning  to  their  normal  relation  to  the  roots  of  the  teeth, 
and  the  saliA^ation  disappears. 


622  PEDIATRICS. 

Diagnosis. — The  differential  diagnosis  of  stomatitis  ulcerosa,  ^\ilen  the 
lesions  of  the  disease  are  marked,  presents  no  difficulty.  Although  an 
herpetic  efflorescence  may  occur  coincidently  with  the  ulcerative  form, 
yet  the  pictures  of  the  two  diseases  are  so  different  that  we  know  at  once 
that  we  are  dealing  with  two  affections  rather  than  with  one.  There  is 
no  other  disease  of  the  mouth  in  which  the  gums  assume  the  puriDlish 
hue  and  the  swollen,  soft,  and  loosened  condition  which  are  character- 
istic of  stomatitis  ulcerosa. 

Prognosis. — The  prognosis  of  stomatitis  ulcerosa  depends  upon  its 
cause  and  whether  it  is  treated  or  not.  The  tendency  is,  however,  after 
a  variable  period  of  discomfort  to  the  child,  for  the  disease  to  disappear. 

If  the  affection  is  the  result  of  one  of  the  constitutional  diseases,  such 
as  syphOis  or  scorbutus,  it  disappears  if  the  treatment  of  the  specific 
disease  is  beneficial,  otherwise  it  continues,  and  may  finally  lead  to  death 
by  exhaustion. 

Treatment. — The  local  form  of  the  disease  is  best  treated  by  the 
internal  administration  of  chlorate  of  potassium  or  by  this  drug  in 
-solution  used  as  a  w^ash  for  the  mouth.  Chlorate  of  potassium  must, 
however,  be  given  with  great  precaution  to  infants  and  children,  as  in 
certain  cases  it  acts  as  a  poison,  some  infants  being  affected  by  even 
minute  doses.  The  symptoms  which  show  that  chlorate  of  potassium  is 
producing  deleterious  effects  in  infants  who  are  most  likely  to  be  affected 
by  the  drug  are  drowsiness  and  suppression  of  urine,  with  weakness  of 
the  heart  and  sometimes  cyanosis.  When  these  symptoms  follow  the 
administration  of  the  drug,  it  should  be  omitted  at  once  and  a  simple 
wash  of  borate  of  sodium  used.  Chlorate  of  potassium  when  given  m- 
ternally  has  been  found  to  be  secreted  in  the  saliva  within  five  or  ten 
minutes,  and  thus  has  an  opportunity  of  producing  a  direct  effect  upon 
the  lesions  of  the  gums.  The  doses  of  chlorate  of  potassium,  which,  it 
has  been  found,  can  be  safely  administered  to  infants  and  children,  should 
be  remembered  when  prescribing  the  drug.  Table  66  gives  the  minimum 
doses  which  can  safely  be  taken  in  the  twenty-four  hours  at  different  ages, 
and  which  are  sufficient  to  produce  the  specific  effect  of  the  drug  in  treat- 
ing cases  of  stomatitis  ulcerosa. 

TABLE   66. 

Amount  of  Chlorate  of  Potassium  which  can  be  safely  given  in  Twenty-four  Hours  at 

Different  Ages. 
Age.  "  Gramme. 


Under  1  year 1 

1  to  2  years 1 

2  to  6  years 2 

6  to  8  years 2 

8  to  14  years 3 


In  order  that  the  chlorate  of  potassium  shall  produce  the  best  effects 
it  should  be  given  frequently.     The  total  amount  for  twenty-four  hours 


DISEASES   OF   THE   MOUTH.  623 

which  is  to  be  given  at  any  special  age  is  to  be  placed  in  a  tumbler  and 
dissolved  in  as  many  tablespoonfuls  of  sterilized  water  as  there  are  doses  to 
be  given  within  the  twenty-four  hours.  Let  us  suppose  that  the  number 
of  hours  which  the  child  sleeps  is  ten  :  then  fourteen  tablespoonfuls  of 
the  solution  should  be  prepared,  and  the  child  should  be  given  one  table- 
spoonful  every  hour  when  it  is  awake.  The  administration  of  chlorate  of 
potassium  at  first  usually  produces  considerable  smarting  and  pain  in  the 
mouth  as  it  passes  over  the  inflamed  surface  of  the  mucous  membrane. 
These  symptoms,  however,  last  for  only  a  short  time,  usually  disappearing 
entirely  after  thirty-six  to  forty-eight  hours. 

Under  this  treatment  the  disease  is  ordinarily  cured  in  a  week  or  ten 
days.  The  treatment  should,  however,  be  continued  for  a  number  of 
days  after  the  mouth  is  apparently  entirely  well. 

When  deeper  ulceration  has  taken  place,  its  disappearance  may  some- 
times be  expedited  by  the  application  of  nitrate  of  silver.  When  a  se- 
ciuestrum  has  formed,  it  must  be  removed.  Frequent  washing  of  the 
mouth  with  sterilized  water  administered  by  means  of  a  dropper  is  also 
very  important,  especially  after  the  taking  of  food.  An  alkaline  diet  is 
indicated. 

Plate  XII.,  facing  page  618,  represents  a  case  of  stomatitis  ulcerosa  in  an  infant 
ten  months  old,  in  whose  mouth  were  shown  the  characteristic  lesions  of  the  disease. 
In  this  case  the  disease  happened  to  be  secondary  to  scorbutus,  the  affection  for  which 
the  infant  was  treated. 

The  infant  had  six  teeth,  and  the  mucous  membrane  was  affected  only  at  the  junc- 
tion of  the  gums  with  the  free  surface  of  the  teeth.  The  other  parts  of  the  mucous 
membrane  of  the  mouth  were  reddened,  but  not  markedly  so.  The  portions  of  the  gums 
affected  were  swollen,  purplish,  loosened,  and  almost  covered  the  teeth.  There  was  a 
considerable  flow  of  saliva,  with  a  fetid  odor  from  the  mouth.  An  appearance  of  this 
kind  is  diagnostic  of  stomatitis  ulcerosa. 

The  following  case  of  stomatitis  ulcerosa  was  apparently  of  local 
origin : 

A  girl,  three  and  a  half  years  old,  had  always  been  healthy,  and  had  had  no 
diseases  of  any  kind.  She  began  to  have  loss  of  appetite,  a  temperature  varying  from 
38.3°  to  39.4°  C.  (101°  to  103°  F.),  and  to  be  very  fretful.  Three  days  later  the 
gums  were  noticed  to  be  swollen,  to  be  of  a  dark-red  color,  and  her  breath  had  a  fetid 
odor.  She  was  rather  apathetic  and  wished  to  remain  in  bed.  There  was  considerable 
salivation.  During  the  first  three  days  her  restlessness  was  so  excessive  at  night  that  0.3 
gramme  (5  grains)  of  bromide  of  potassium  had  to  be  given  to  her  to  produce  sleep. 

In  two  or  three  days  more  the  disease  ran  its  course,  and  entire  recovery  took  place. 

STOMATITIS    MYCETOGENETICA. 

There  are  three  forms  of  vegetable  parasites  which  occur  in  or  upon 

the  human  body  :  (1)  bacteria,  or  fission-fungi  (schizomycetes) ;  (2)  yeasts, 

or  yeast-fungi  (saccharomycetes) ;  (3)  moulds,  or  mould-fungi  (hyphomy- 

cetes).     The  changes  in  the  tissues  which  are  due  to  fungi  are  termed 


(324  I'EDIATRICS. 

mycdogenetic  inetainorphosis,  and  thus  the  pathological  conditions  in  the 
moutli  which  are  produced  by  any  of  these  forms  of  fungi  may  be 
designated  by  the  general  term  mycetogeaetica.  Under  this  general  head- 
mg  of  mycetogenetica  we  can  include  the  various  forms  of  stomatitis 
which  are  caused  by  fungi.. 

Stomatitis  Hyphomycetica  {tfirush). — ^Etiology. — The  disease  whicli 
is  commonly  called  thrush  is  produced  by  a  fungus  which  finds  its  nidus 
upon  the  surface  of  the  mucous  membrane  of  the  mouth,  usually  hi 
young  infants.  This  fungus  was  formerly  supposed  to  be  the  oidiuni  albi- 
cans, but  it  is  now  known  not  to  be  this  organism,  and  the  precise  form 
of  mould  which  it  represents  has  not  yet  been  determined.  We  merely 
know  that  this  growth  of  thrush  is  one  of  the  mould-fungi,  and  we  can 
therefore  at  present  only  classify  it  as  stomafifis  hyphomycefk-a. 

The  moulds  are  complex  m  their  structure,  and  as  commonly  de- 
scribed consist  of  a  series  of  delicate  jointed  threads  [mycelium)  in  which 
spores  are  developed.  Hyphomycetic  growth  is  characterized  by  having 
the  spores  naked  on  conspicuous  threads.  The  fungus  of  thrush  may  be 
found  on  any  of  the  mucous  membranes  of  the  body.  It  has  also  been 
found  in  various  organs,  as  in  the  brain  and  tlie  lungs,  and  from  the 
surface  of  ulcers  it  has  on  rare  occasions  penetrated  the  blood-vessels 
and  given  rise  to  visceral  metastases.  The  usual  place  for  it  to  appear, 
however,  is  the  mucous  membrane  of  the  mouth.  It  is  a  local  disease, 
and  may  occur  in  the  mouths  of  healthy  children  as  well  as  in  those 
who  are  diseased.  It  is  more  likely,  however,  to  be  ingrafted  upon  a 
diseased  than  upon  a  healthy  mucous  membrane,  in  accordance  with  the 
rule  which  we  have  already  stated.  A  catarrhal  condition  of  the  mucous 
membrane,  by  displacing  the  epithelial  cells  and  thus  interfering  with  their 
protection  of  the  mucous  membrane,  affords  the  readiest  means  for  the 
development  of  the  fungus  of  thrush.  It  is  therefore  more  likely  to  be 
found  in  the  mouths  of  children  who  are  suffering  from  various  diseases 
or  who  are  ill  cared  for.  It  may  be  carried  to  the  mouth  m  various  ways, 
either  on  dirty  nipples  or  by  the  finger. 

Pathological  Anatomy. — The  growth  may  take  place  on  both  squamous 
and  cylindrical  epithelium.  According  to  Forchheimer,  the  first  lodgement 
of  the  fungus  comes  between  the  epithelial  cells  of  the  mouth,  and  from 
this  the  growth  works  its  way  under  the  free  surface  of  the  mucous  mem- 
brane. When  directly  on  the  free  surface  the  growth  is  not  so  luxuriant 
and  is  principally  m  the  mycelium  form.  In  the  case  of  a  mucous  mem- 
brane lined  by  flat  or  squamous  epithelium,  the  growth  is  facilitated  by 
the  relation  of  the  cells  to  one  another.  In  a  meniJDrane  lined  by  cylin- 
drical epithehum.  the  growth  takes  place,  but  not  so  readily,  because  there 
is  but  one  layer  of  cells.  After  the  first  development  the  growth  goes 
on  very  rapidly,  and  after  it  has  found  a  nidus  the  cells  are  pushed  aside 
and  are  surrounded  by  mycelium,  the  whole  presenting  the  characteristic 
appearance  of  thrush.     The  growth  begins  in  small  spots,  sometimes  one, 


DISEASES    OF    THE    MOUTH.  625 

sometimes  more,  and  at  times  the  entire  surface  of  the  mucous  membrane 
is  covered  with  it.  The  fungus  develops  within  the  epithehum,  and  it 
requires  considerable  rubbing  to  remove  the  growth. 

Symptoms. — An  attack  of  thrush  usually  begins  with  local  symptoms 
of  catarrhal  stomatitis.  At  times,  however,  no  symptoms  are  present, 
the  fungus  being  the  first  abnormal  condition  which  is  noticed.  The 
appearance  of  the  fungus  resembles  closely  that  of  curdled  milk,  though 
it  is  often  of  a  rather  grayish  color.  It  does  not  look  like  a  membranous 
exudation,  but  is  raised  in  small  patches  above  the  level  of  the  mucous 
membrane.  The"  fungus  usually  develops  on  the  inner  borders  of  the 
lips,  on  the  gums,  on  the  tongue,  and  on  the  hard  and  the  soft  palate.  It 
may  extend  to  the  tonsils  and  phan-nx,  and  even  into  the  oesophagus.  In 
the  latter  locality  at  times  it  has  been  found  to  grow  so  thickly  that  the 
lumen  is  almost  entirely  occluded.  The  local  symptoms  are  commonly 
those  of  a  mild  catarrhal  stomatitis.  The  general  symptoms  depend  upon 
the  extent  of  the  local  disease  from  which  the  infant  is  suffermg.  Infants 
affected  with  this  disease  soon  become  atrophic,  from  a  lack  of  proper 
nourishment,  as  they  are  often  unwilling  to  take  their  food  or  cannot 
swallow  it  without  difficulty. 

Diagnosis. — The  differential  diagnosis  is  seldom  difficult  to  make. 
Curdled  masses  of  milk  on  the  inner  surfaces  of  the  lips  and  on  the 
gums  may  resemble  closely  the  fungus  of  thrush,  but  the  former  is  easily 
wiped  away,  while  the  latter  is  difficult  to  dislodge.  The  disease  is 
definitively  determined  by  placing  some  of  the  growth  under  the  micro- 
scope, where  it  presents  characteristic  appearances. 

Prognosis. — The  prognosis  of  thrush  varies  according  to  the  general 
condition,  the  vitality,  and  the  age  of  the  subject  on  whom  it  is  en- 
grafted. The  disease  may  last  indefinitely  if  the  mouth  is  not  carefully 
treated,  and  its  prol-ongation  may  render  the  prognosis  more  grave.  When 
the  growth  is  very  extensive,  as  in  the  cases  in  which  it  has  invaded  the 
oesophagus,  the  prognosis  is  very  unfavorable.  In  these  cases  disturbances 
of  the  gastro-enteric  tract  are  apt  to  arise  and  to  increase  the  likelihood 
of  a  fatal  issue.  As  a  rule,  however,  if  the  infant's  health  can  be  main- 
tained, and  if  the  local  treatment  is  carried  out  thoroughly,  the  prognosis 
is  favorable. 

Treatment. — The  treatment  should  be  directed  to  the  local  care  of  the 
mouth  and  to  supporting  the  strength  by  proper  nourishment  and  stimu- 
lants until  the  fungus  has  been  eradicated.  Care  should  be  taken  that 
everything  connected  with  the  infant,  especially  the  nipples  and  bottles 
from  which  it  is  to  be  fed,  should  be  aseptic,  so  that  it  shall  not  be  con- 
tinually reinfected  or  infect  other  children.  The  mouth  after  each  feeding, 
and  also  between  the  feedings,  should  be  thoroughly  and  some'what  vig- 
orously rubbed  with  the  solution  which  has  already  been  recommended  in 
the  treatment  of  stomatitis  catarrhalis. 

When  the  disease  is  in  the  a?sophagus  it  is  best  treated  by  the  intro- 

40 


626 


PEDIATRICS. 


duction  of  a  soft  rubber  tube,  in  order  that  the  growth  may  thus  be  me- 
chanically separated  from  the  mucous  membrane. 

In  many  cases  the  disease  is  very  intractable.  No  special  drug  appears 
to  be  of  use  in  these  cases,  and  they  can  be  cured  only  by  the  unremitting 
and  patient  removal  of  the  growth  as  just  described. 


Plate  XII.,  facing  page  618,  Thrush,  represents  the  mouth  of  an  infant  three 
months  old,  who  refused  to  take  the  bottle  for  a  month,  was  emaciated  and  fretfuL 
and  at  times  vomited. 

A  careful  physical  examination  failed  to  detect  anything  abnormal  except  in  the 
infant's  mouth.  On  gently  depressing  the  tongue  and  lower  jaw,  it  was  seen  that  the 
soft  and  the  hard  palate,  the  tongue,  the  gums,  and  the  inner  surface  of  the  lips  were 
covered  almost  entirely  with  white  and  grayish-white  masses,  in  texture  somewhat  re- 
sembling curdled  milk,  and  rising  above  the  level  of  the  epithelium.  Between  these 
patches  the  mucous  membrane  was  reddened.  There  was  a  moderate  flow  of  saliva. 
This  morbid  gro^vth  apparently  did  not  extend  into  the  pharynx.  The  patches  could 
not  be  removed  readily,  as  would  be  the  case  if  it  were  curdled  milk,  and  the  growth 
evidently  passed  between  the  epithelial  cells  down  to  the  underlying  mucous  mem- 
brane, where  it  was  held  so  closely  that  it  required  considerable  rubbing  to  separate  it. 
In  this  case  the  growth  was  so  extensive  that  it  simulated  a  membrane  in  some  places, 
but  its  generally  roughened  surface,  its  elevation  above  the  level  of  the  mucous  mem- 
brane, and  the  characteristic  appearances  in  other  parts  of  the  mouth  rendered  its 
recognition  quite  simple. 

On  placing  some  particles  of  this  growth  in  glycerin  under  the  microscope  a 
tangled  mass  of  fine,  almost  translucent,  membered  threads  were  seen  as  represented 
in  Fig.  130. 

Fig.  130. 


Mycelium  of  thrash  interspersed  -n-ith  spores  and  fatty  desrenerated  cells.     (Low  power  Zeiss  Oc.  3- 

Otajective  DD,  glycerin.) 

Interspersed  among  these  threads  were  bright,  glistening,  oval  bodies,  which  were 
the  formed  spores,  and  also  fatty  degenerated  cells  and  fine  detritus.  This  combi- 
nation of  appearances  represents  the  pathological  processes  which  we  find  in  thrush. 


DISEASES   OF   THE   MOUTH. 


627 


Fig.  131  represents  some  shreds  from  the  same  specimen,  but  much  more  highly 
magnified.     In  this  specimen  can  be  seen  the  formation  of  the  spores  in  the  mycelium. 


Pig.   131. 


Thrush  sliowlng  the  formation  of  spores  in  the  mycelium.     fZeiss  Oc.  3,  homogen.  immer.  2.0  mm.) 

Stomatitis  Pseudo-Membranosa. — Under  this  heading  we  shall  merely 
refer  to  those  pseudo-membranous  conditions  which  occur  in  diphtheria, 
tuberculosis,  syphilis,  and  diseases  of  a  like  class.  The  former  two  are 
so  rarely  seen  in  the  mucous  membrane  of  the  mouth  that  it  is  not  neces- 
sary to  describe  them.  The  lesions  which  occur  in  the  mouth  in  syphilis 
have  already  been  described  when  speaking  of  that  disease. 

Stomatitis  Gangrsenosa  (noma,  ccmcrmn  oris). — Stomatitis  grangrse- 
nosa  is  the  rarest  and  most  fatal  form  of  stomatitis  which  occurs  in 
children.  It  is  usually  met  with  between  the  ages  of  three  and  seven 
y^ears.  It  is  a  disease  characterized  by  a  gangrsenous  process  which  begins 
on  the  gums  or  on  the  inner  surface  of  the  cheek  and  spreads  with  great 
rapidity  to  the  adjoining  tissues,  all  of  which  can  be  involved  and  quickly 
destroyed. 

Etiology. — A  number  of  organisms  have  been  found  associated  with 
the  lesions  of  noma,  but  there  is  no  definite  proof  that  any  one  of  them  is 
the  actual  cause.  It  is  supposed  that  it  does  not  attack  a  healthy  mucous 
membrane,  and  that  one  of  the  other  forms  of  stomatitis,  especially  stoma- 
titis catarrhalis,  and  in  some  cases  s' omatitis  ulcerosa,  precedes  it.  Further- 
more, stomatitis  gangraenosa  seldom  attacks  healthy  children,  but  usually 
affects  those  who  have  other  diseases  and  are  greatly  debilitated.  It  occurs 
most  commonly  secondarily  to  the  acute  exanthemata,  especially  measles. 


628 


PEDIATRICS. 


The  disease  is  also  said  to  result  from  the  administration  of  mercury  in  too 
large  doses. 

It  begins  as  a  reddened,  hard  spot  in  the  mucous  membrane,  usually 
of  the  cheek.  This  soon  becomes  gangrenous  and  extends  rapidly  through 
the  entire  thickness  of  the  cheek,  producing  perforation.  It  may  also  extend 
laterally  in  all  directions,  attacking  the  bone  as  well  as  the  other  tissues. 

Symptoms. — The  first  symptom  which  is  apt  to  be  noticed  is  the  gan- 
grenous odor  Avliich  comes  from  the  mouth.  On  examination  an  ulcer 
will  be  found  which  tends  to  spread  rapidly.  The  cheek  becomes  much 
swollen,  is  hard  and  edematous,  the  rede  ma  especially  affecting  the 
tissues  under  the  eye.  The  gangrenous  process  extends  very  rapidly, 
at  times  destrojing  large  portions  of  the  face,  and  also  involving  the 
bones,  which  become  denuded.  The  teeth  become  loose  and  fall  out. 
The  odor  from  the  gangrenous  tissue  is  excessive.  The  flow  of  saliva  is 
very  much  increased.  The  degree  of  suffering  which  the  children 
midergo  varies  very  much ;  sometimes  it  seems  as  if  they  suffered  no 
pain  whatever.  The  temperature  A'aries,  at  times  being  raised  and  again 
being  subnormal.  The  pulse  is  weak  and  rapid.  The  appetite  is  dimin- 
ished, and  the  children  are  likely  to  have  diarrhoea,  probably  due  to  the 
infectious  nature  of  the  products  of  the  mouth  which  are  swallowed. 
Hemon'hages  are  rather  rare,  accordmg  to  Forchheimer,  as  the  blood- 
vessels are  usually  fdled  with"  thrombi.  .  Secondary  affections,  such  as 
catarrhal  pneumonia  from  the  inhalation  of  septic  material,  are  not  un- 
common. The  child  may  die  from  one  of  these  secondary  affections,  or 
it  may  become  more  and  more  weakened  by  the  local  condition,  and 
unless  the  morbid  process  is  arrested  it  will  die  eventually  from  ex- 
haustion. 

Diagnosis, — The  diagnosis  of  this  disease,  except  in  its  earlier  stages, 
is  not  difficult.  At  tmies,  however,  a  local  ulcerative  process  produced 
by  a  decayed  tooth  may  sunulate  closely  stomatitis  gangraenosa.  In  these 
cases  the  diagnosis  is  made  more  difficult  by  the  fact  that  the  tissues  of 
^ — 4he  cheek  may  become  hard  and  look  as  though  perforation  might  take 
place.  Coincidently  with  this  condition  the  ulceration  of  the  gum  and 
often  of  the  mucous  membrane  of  the  cheek,  with  the  foul  odor  which 
emanates  from  it.  makes  the  similarity  of  the  two  diseases  ven'  striking. 
In  simple  ulceration  from  a  tooth,  however,  active  local  treatment  with 
solutions  of  m\Trh  or  of  soda  combmed  with  frequent  washing  of  the 
mouth  with  sterilized  water  is  soon  followed  by  marked  improvement, 
while  when  stomatitis  gangraenosa  is  present  the  morbid  process  con- 
tmues  to  extend. 

Prognosis. — The  prognosis  in  cases  of  stomatitis  gangraenosa  which 
are  untreated  is  almost  universally  fatal.  Cases  have  been  biown,  how- 
ever, in  which  a  line  of  demarcation  has  formed  around  the  gangrenous 
spot,  granulations  have  arisen,  and  cicatrization  has  followed,  leaving 
extensive  scars.     If  the  disease  is  treated  by  extfrpation  of  the  diseased 


DISEAr?ES    OF   THE    MOUTH.  629 

tissues  in  the  very  beginning,  the  prognosis  becomes  more  favorable. 
When  the  disease  has  perforated  the  cheek  and  the  gangrenous  process 
has  become  extensive,  the  child  is  seldom  relieved  even  by  surgical 
treatment. 

Treatment. — Care  should  be  taken  ^vhen  a  child  is  affected  with  a 
disease  of  an  exhausting  nature  that  its  mouth  is  kept  thoroughly  cleansed, 
for  we  can  never  tell  when  or  in  what  individual  the  mucous  membrane 
may  become  vulneralDle  to  the  organism  which  produces  stomatitis  gan- 
grsenosa.  In  stomatitis  gangrgenosa  it  is  very  important  for  the  success 
of  the  treatment  that  it  should  be  begun  very  early  in  the  disease.  When 
the  diagnosis  has  been  definitely  made,  it  is  wiser  not  to  temporize  with 
applications  of  nitrate  of  silver  and  other  drugs,  but  at  once  to  place  the 
case  in  the  hands  of  a  surgeon  and  have  the  entire  area  of  the  invaded 
tissues  excised.  It  is  also  well  after  the  gangrenous  process  has  been 
removed  by  the  knife  to  destroy  an  area  of  healthy  tissue  by  means  of 
the  Paquelin  thermo-cautery  or  by  the  galvano-cautery.  There  should 
be  no  delay  in  operating  upon  these  cases,  as  great  destruction  of  the 
tissues  may  take  place  m  even  a  few  hours. 

After  the  operation  the  tissues  should  be  inspected  frec|uently,  to  see 
whether  there  is  any  return  of  the  gangrenous  spots,  and,  if  found,  these 
spots  should  be  removed  mimediately.  As  the  disease  is  very  apt  to 
recur,  plastic  operations  to  obviate  defonnity  should  not  be  undertaken 
very  early  after  the  operation. 

In  treatmg  these  cases  surgically  it  must  be  remembered  that  the 
child  is  in  a  verj-  debilitated  condition,  and  that  if  it  is  suffering  from  any 
especial  disease  treatment  directed  to  that  disease  is  indicated,  also  that 
stimulants  are  required  to  prevent  the  already  weakened  child  from  dnng 
of  exhaustion  following  the  operation. 

The  following  case,  a  girl  four  years  old,  represented  in  Fig.  132,  was 
brought  to  the  hospital  to  be  operated  on  for  stomatitis  gangTcenosa, 

In  this  case  the  disease  was  apparently  primary,  and  began  on  the  left  side  of  the 
mucous  membrane  of  the  mouth.  It  spread  rapidly,  and,  although  treated  by  local 
applications  to  the  mouth  of  various  solutions,  had  broken  through  the  left  cheek 
close  to  the  ala  nasi.  The  teeth  were  loose  in  the  middle  of  the  upper  jaw,  and  there 
was  a  certain  amount  of  alveolar  necrosis.  There  was  a  strong  gangrenous  odor 
from  the  mouth  and  the  tissues  of  the  cheek,  and  a  considerable  flow  of  saliva.  The 
child's  general  condition  was  fair,  but  she  was  becoming  more  debilitated,  had  lost  her 
appetite,  and  had  a  slightly  raised  temperature. 

The  cheek  was  operated  on  the  day  after  the  child  entered  the  hospital.  The 
wound  healed  readily.  One  year  later  the  child  again  returned  to  the  hospital.  The 
right  cheek  was  found  to  be  much  swollen  and  indurated,  especially  under  the  right 
eye.  The  periosteum  of  the  lower  jaw  on  the  right  side  was  affected,  and  the  necrotic 
process  had  undermined  the  whole  cheek  as  far  as  the  orbit.  The  child  was  again 
operated  on  without  any  external  opening  of  the  cheek.  The  wound  healed,  and  the 
child  was  discharged  from  the  hospital,  but  returned  some  months  later  with  a  spon^ 
taneous  opening  on  the  right  cheek.  This  was  again  apparently  cured  by  operation. 
Two  months  later  the  child  was  found  to  have  in  the  lower  jaw  a  process  similar  to 


630 


PEDIATRICS. 


that  which  had  occurred  in  the  upper  jaw.  Her  health  was  poor,  she  was  pale  and 
weak  and  had  loss  of  appetite.  She  was  operated  upon  again,  and  a  sequestrum  was 
removed  from  the  lower  jaw.  She  then  improved.  Some  months  later  she  was  ap- 
parently in  fair  health. 

Pm.   W2. 


Stomatitis  gaiigrajuosa,  left  cheek.    Female,  4  years  old. 

The  microscopic  examination  of  the  gangrenous  tissues  removed  at  the  operation 
presented  nothing  significant  of  any  especial  disease,  and  a  culture  showed  only  a  few 
streptococci. 

Fto.    133. 


1^ 

^ 

^^^^^^^ 

^B  ^ 

^aL        f-% 

H^BH^^.            ^i        1 

Ifpr  ^ 

l>-*' 

^^ 

stomatitis  gangrsenosa  secondary  to  measles  and  pneumonia.    Female,  5  years  old. 

The  following  case  of  stomatitis  gangrsenosa  occurred  in  a  girl  five 
years  old : 

The  disease  was  preceded  by  pertussis,  measles,  and  a  broncho-pneumonia. 
After  she  had  had  the  pneumonia  for  seventeen  days  her  right  cheek  began  to  swell  and 
a  bad  odor  came  from  her  mouth,  but  nothing  especial  could  be  found  in  the  mucous 
membrane  of  the  buccal  cavity.     Four  days  later  the  swelling  of  the  cheek  had  much 


DISEASES  OF  THE   MOUTH.  631 

increased,  and  there  was  oedema  of  the  lips  and  eyelid  so  that  the  right  eye  was  partly 
closed.  The  swelling  was  semi-fluctuating.  The  temperature  varied  from  38.3°  to 
39.4°  C.  (101°  to  103°  F.),  and  the  cough  had  much  lessened.  On  the  following  day 
a  bluish-black  spot  about  1.5  cm.  (|  inch)  in  circumference  appeared  at  the  right  cor- 
ner of  the  mouth,  and  this  rapidly  increased  during  the  day.  Two  days  later  the  dark- 
colored  area  had  increased  considerably  in  size  and  presented  a  circular  outline  with  a 
clearly  marked  line  of  demarcation. 

The  child  also  had  a  profuse  greenish  diarrhoea.  On  the  following  day  the  dark 
area  rapidly  extended,  and  soon  involved  the  whole  of  the  right  cheek,  the  right  side 
of  the  mouth,  and  the  right  nostril.  There  was  no  external  loss  of  tissue.  The  child 
was  extremely  emaciated,  and  from  the  beginning  of  the  attack  was  in  a  hopeless  con- 
dition, so  that  radical  treatment  of  the  disease  was  deemed  inadvisable.  It  died 
suddenly  on  the  following  day.     Fig.  133  represents  the  case. 


GLOSSITIS. 

Glossitis  is  so  rare  a  disease  in  children  that  the  possibility  of  its 
occurrence  only  need  be  mentioned.  In  this  affection  there  is  an  acute 
inflammation  of  the  tissues  of  the  tongue,  accompanied  by  fever,  enlarge- 
ment of  the  organ,  and  considerable  pain.  There  is  usually  a  hyper- 
secretion of  saliva,  and  at  times  the  obstruction  to  respiration  from  the 
occlusion  of  the  throat  by  the  greatly  enlarged  tongue  produces  somewhat 
alarming  symptoms,  though,  as  a  rule,  not  serious  ones. 

This  disease  may  be  caused  by  direct  injury  to  the  tongue  from  corro- 
sive substances,  by  heat,  or  by  the  stings  of  animals,  and  sometimes 
probably  by  sepsis.  It  runs  a  variable  course  ;  it  is  not  especially  seri- 
ous, and  tends  to  recover  after  a  few  days.  The  treatment  is  purely 
symptomatic.  The  frequent  local  application  of  ice  and  of  ice-cold  alka- 
line solutions  to  the  tongue  and  mouth  is  indicated. 

LINGUA  GEOGRAPHIOA. 

A  condition  of  the  dorsum  of  the  tongue  is  sometimes  met  with, 
which,  for  want  of  a  better  name,  is  called  lingua  geographica,  "  mappy 
tongue,"  or  "wandering  rash."  One  or  more  smah  patches  appear  on 
the  dorsum  or  side  of  the  tongue,  which  in  a  few  days  may  spread  and 
coalesce,  often  covering  a  large  portion  of  the  surface.  They  diminish 
in  size  or  fade  with  equal  rapidity,  to  recur  at  variable  periods.  The 
patches  are  red  and  smooth,  and  the  filiform  papillae  are  absent.  The 
rest  of  the  tongue  appears  normal,  except  that  the  papillae  on  the  borders 
of  the  denuded  portions  are  white  and  prominent.  The  etiology  of  the 
disease  is  unknown.  It  occurs  almost  exclusively  in  children  or  in  young 
adults  who  have  been  subject  to  it  from  childhood.  It  is  very  benign, 
and  gives  no  discomfort  to  the  child.  Its  principal  importance  Hes  in  the 
fact  that  it  is  sometimes  mistaken  for  a  symptom  of  some  more  serious 
disease.  No  form  of  treatment  has  been  found  useful.  It  recurs  peri- 
odically for  months  or  years,  but  does  not  tend  to  increase  in  severity  nor 
to  lead  to  other  diseases. 


()32 


PEDIATRICS. 


MICROGLOSSIA. 

In  some  individuals  an  arrest  of  development  of  the  tongue  produces  the 

condition  called  microglossia,  in  which  the  tongue  is  to  a  varying  degree 

smaller  than  normal. 

MACROGLOSSIA. 

The  opposite  condition,  macroglossia,  in  which  the  tongue  is  enlarged, 
is  more  common  than  microglossia.  It  is  usually  a  congenital  lesion,  and 
is  especially  marked  in  cretins.  The  prominent  feature  of  the  affection 
is  a  prolapse  of  the  tongue,  which  is  often  enormously  enlarged  in  every 
direction,  is  usually  of  a  deep  violet  color,  and  is  covered  with  a  thick, 
whitish  coat.  The  protruded  tongue  is  indented  and  even  ulcerated  by 
the  teeth,  which  are  often  pushed  forward  and  become  carious.  The 
saliva  flows  continuously  from  the  mouth,  the  lower  lip  becomes  thick  and 
ulcerated,  and  the  forcing  forward  of  the  lip,  larynx,  and  velum  palati 
by  the  weight  of  the  tongue  renders  suction,  mastication,  and  deglutition 
difficult.  The  nutrition  of  the  child  is  thus  much  interfered  with,  and 
this  interference  is  one  of  the  most  serious  results  of  the  disease.  This 
condition  is  not  a  glossitis,  but  a  deformity  which  seems  to  be  associated 
with  certain  other  malformations  of  the  body.  In  these  individuals  the 
hands  and  feet  are  apt  to  be  large,  thick,  and  purplish. 

Macroglossia  appears  in  two  forms.  One  is  the  fibrous,  in  which  the 
connective  tissue  is  pathologically  increased  between  the  muscular  fibres. 
The  other  is  a  cavernous  cystoid  degeneration  of  the  interstitial  connec- 
tive tissue,  by  which  the  resulting  spaces  come  in  connection  with  the 
lymph-vessels,  constituting  a  condition  closely  resembling  cavernous 
angioma,  from  which  it  receives  its  name  of  lymphangioma  cavernosum. 

The  disease  seldom  tends  to  recover,  and  the  treatment  is  to  give  as 
much  relief  as  possil^le  to  the  great  discomfort  which  arises  from  it,  by 
cleansing  the  mouth  frequently  with  alkaline  solutions.  Especial  care 
should  be  directed  to  the  nourishment  of  the  child.  In  extreme  cases 
-surgical  interference  is  indicated  when  the  child's  respiration  and  general 
nutrition  are  affected,  and  in  some  cases  great  improvement  is  accom- 
plished by  the  removal  of  part  of  the  tongue. 

DIFFICULT  DENTITION. 
The  normal  development  of  the  teeth  in  infancy  and  childhood  is  a 
physiological  process.  The  teeth  are  developed  at  birth  to  a  certain  de- 
gree, and  merely  increase  in  size  during  infancy  until  they  pierce  the 
gums  and  assume  their  places  in  the  mouth.  In  many  cases  the  process 
of  dentition  gives  rise  to  no  morbid  conditions  wiiatever.  The  idea  that 
dentition  occasions  the  various  diseases  with  which  it  was  formerly  sup- 
posed to  be  associated  is  an  erroneous  one.  From  the  fourth  or  fifth 
month,  however,  until  the  completion  of  dentition  in  the  latter  part  of 
infancy,  various  nen^ous  disturbances  are  so  closely  associated  with  irrita- 
tion in  the  mouth  that  in  this  sense  dentition  may  be  considered  respon- 


DISEASES   OF   THE   MOUTH. 


633 


Fig.   134. 


® 


sible  for  many  of  the  slight  aihiients  which  arise  at  this  period  of  life. 
The  mouth  at  this  time  frequently  becomes  hot,  and  sometimes  dry, 
although  there  may  be  a  hypersecretion  of  saliva.  There  is  evidently 
much  discomfort  in  the  region  of  the  gums,  as  the  infant  is  continually 
rubbing  them  Avith  its  fingers  and  seems  to  get  relief  from  biting  on  hard 
substances.  Sucli  infants  may  become  mucli  prostrated  and  may  lose 
their  appetite,  and  thus  their  nutrition  may  be  interfered  with,  without 
any  discoverable  cause  for  these  abnormal  conditio.ns  beyond  the  general 
nervous  irritation  which  arises  from  the  feeling  of  discomfort  in  the  mouth 
and  head.  In  the  more  extreme  cases  the  infant  will  be  so  restless  at 
night  that  it  scarcely  lies  still  for  half  an  hour  at  a  time,  and  may  spend 
night  after  night  crying  out  occasionally  as  though  in  pain,  and  knocking 
its  head  against  the  sides  of  its  crib,  so  that  in  some  cases  the  crib  will 
have  to  be  padded.  These  infants  also  have 
to  be  guarded  sometimes  from  knocking 
their  heads  against  the  floor  or  Avail,  as  they 
seem  to  become  almost  frantic  from  the  con- 
tinued irritation  from  Avhich  they  are  suf- 
fering. These  symptoms  occur  Avith  such 
regularity  at  a  time  when  a  tooth  is  in  its 
final  stage  of  development,  and  cease  so 
uniformly  when  the  tooth  has  attained  its 
growth,  that  the  causal  relation  betAveen  the 
tooth  and  these  nervous  symptoms  seems 
more  than  probable.  This  rather  indefinite 
clinical  association  of  dentition  and  nervous 
symptoms  is,  hoAvever,  partially  explained 
by  the  analogous  symptoms  arising  from  the 
anatoinical  relationship  which  exists  betAveen 
tlie  roots  of  the  teeth  and  the  ear.  It  has 
long  been  noticed  that  in  certain  infants, 
during  the  completion  of  the  development 
of  a  tooth,   symptoms   connected  Avith   the 

ear  Avill  manifest  themselves.  These  symptoms  are  usually  produced  by 
a  congestion  of  the  blood-vessels  of  the  ear,  Avhich  is  accompanied  by 
pain,  and  sometimes  results  in  inflammation.  They  are  evidently  of 
reflex  "origin.  Fig.  134  explains  the  influences  which  an  irritation  of  some 
distant  part  of  the  economy  may  exert  on  the  blood-vessels  of  the  ear. 

The  general  vascular  disturbance  in  the  ear,  represented  either  by 
an  uncomfortable  feeling  of  fulness  or  by  general  pain,  may  be  produced 
in  cases  of  difficult  dentition  by  this  close  connection  betAveen  the  sensori- 
motor nerves  and  the  sympathetic.  According  to  Woakes,  a  considerable 
portion  of  the  blood-supply  of  the  membrane  of  the  drum  is  derived  from 
the  artery  that  leaves  the  internal  carotid  in  the  carotid  canal  and  pro- 
ceeds bv  a  verv  short  course   directly  to  its   destination.     Being  thus 


A,  sympathetic  ganglion ;  B,  sen- 
sori-motor  nerve ;  0,  afferent  sympa- 
thetic fibres  from  sheath  of  B ;  D, 
caudate  cells  ;  E,  efferent  sympathetic 
fibres  proceeding  to  artery/;  F,  artery 
dilated  ;/,  normal  size  of  artery  beyond 
the  sympathetic  influence;  G,  general 
vasomotor  centre ;  H,  H,  the  dotted 
lines  indicating  the  course  of  the  fibres 
forming  the  roots  of  the  ganglion  in 
the  spinal  cord  to  the  general  vaso- 
motor centre  G.     (Woakes.) 


G34 


PEDIATRICS. 


Fig.   135. 


•^■0 


A,  tympanic  cavity ;  B,  otic 
ganglion ;  C,  tooth ;  D,  internal 
carotid  ;  E,  tympanic  branch  ;  F, 
auriculo-temporal  nerve ;  G,  au- 
ricular branch  of  auriculo-tem- 
poral nerve.  The  dotted  line 
connecting  B  and  C  represents 
the  inferior  dental  nerve. 


closely  connected  with  a  large  arterial  trunk,  this  small  tympanic  branch 
.is  very  favorably  situated  for  a  speedy  augmentation  of  its  blood-supply. 
The  nervi  vasorum  constituting  the  carotid  plexus  at  this  part  of  its  course 

come  largely  from  the  otic  ganglion.  On  the 
other  hand,  the  inferior  dental  nerve  supplying 
the  gums  and  the  teeth  also  communicates  with 
this  ganglion. 

We  thus  arrive  at  a  direct  channel  of  nerve 
communication  between  the  source  of  irritation 
in  the  mouth  and  the  vascular  supply  of  the 
drum-head.  The  earache  which  arises  in  these 
cases  is  produced  by  the  vessels  of  the  mem- 
brana  tympani,  which  become  greatly  distended, 
and  the  accompanying  stretching  of  the  tense 
and  sensitive  tissue  in  which  this  occurs  ac- 
counts for  the  pain. 

Fig.  135  represents  the  anatomical  nervous 
connection  between  the  teeth  and  the  membrana 
tympani. 

It  is  thus  seen  that  a  great  many  symptoms, 
usually  of  slight  import,  but  marked  enough  to 
give  much  discomfort  to  the  infant,  may  arise  during  this  period  of  den- 
tition, when  the  infant's  entire  nervous  system  seems  to  be  in  a  very 
sensitive  condition. 

Gum-Lancing-. — The  question  of  lancing  the  gums  during  the  period 
of  dentition  is  one  which  has  given  rise  to  much  discussion  and  to  very 
diverse  opinions.  In  former  times  it  was  erroneously  believed  that  the 
teeth  played  an  important  part  in  almost  every  disease  which  occurred  in 
early  life.  It  was  also  supposed  that  lancing  the  gum  relieved  the  symp- 
toms of  these  diseases  in  some  unexplained  way.  This  extreme  view 
soon  had  to  be  modified,  and  of  late  years  many  observers  have  come  to 
the  conclusion  that  it  is  never  necessary  to  lance  the  gums.  In  cases  of 
difficult  dentition,  however,  as  just  explained,  irritation  arises  very  com- 
monly in  the  later  stages  of  the  development  of  a  tooth,  and  the  question 
therefore  remains  whether  this  irritation  in  various  parts  of  the  economy, 
notably  in  the  ear,  can  be  relieved  by  lancing  the  gum.  With  regard  to 
the  question  of  gum-lancing,  it  may  be  said  that  it  should  be  resorted  to 
only  under  very  exceptional  circumstances. 

During  the  dental  period  two  classes  of  irritation  are  met  with  in  con- 
nection with  the  teeth:  (1)  irritation  of  the  dental  nerves,  with  symptoms 
of  reflex  aural  disturbance ;  and  (2)  irritation  of  the  gum  over  the  crown 
of  the  tooth  from  pressure,  with  symptoms  of  local  irritation.  We  here 
have  two  entirely  different  conditions.  If,  when  pain  or  symptoms  in 
some  other  part  of  the  economy  seem  to  arise  from  dental  irritation,  we 
find  that  the  gum  which  covers  the  crown  of  the  still  undeveloped  tooth 


DISEASES   OF   THE   MOUTH.  635 

is  soft  and  flat  as  in  other  parts  of  the  mouth  "where  a  tooth  is  not  about 
to  come  through,  lancing  the  gums  is  manifestly  absurd,  as  there  is  evi- 
dently no  reason  for  making  a  Avound  in  the  mouth. 

The  second  class  of  cases,  however,  although  rather  rare,  must  still 
be  recognized  as  distinct  in  themselves  and  requiring  especial  treatment. 
In  this  class  it  is  very  evident  that  the  gum  for  some  reason  does  not  give 
way  to  the  growth  of  the  tooth.  Where  the  gum  covers  the  crown  of 
the  tooth  the  tissues  are  swollen,  tense,  almost  cartilaginous  in  their  feel- 
ing, and  hot.  AVhen  this  combination  of  alDnormal  conditions  is  found 
over  the  crown  of  the  tooth,  it  can  be  relieved  at  once  by  the  lancet. 

Figs.  136  and  137  represent  the  condition  of  the  gums  in  relation  to  the 
teeth  in  the  two  classes  of  cases  which  have  just  ])een  mentioned.  Fig. 
136  represents  the  mucous  membrane  over  the  crown  of  the  tooth  as  flat 
and  on  a  level  with  the  rest  of  the  gum.     This  is  the  condition  of  the 

Fig.   136. 
C 


D         ^  D 

A,  tooth  in  bone  socket ;  B,  jaw-bone ;  C,  gum,  soft,         A,  tooth  in  bone  socket ;  B,  jaw-bone  ;  C,  g:uin, 
not  inflamed  or  swollen  ;  D,  dental  nerre.  tense,  inflamed,  swollen  ;  D,  dental  nerve. 

gum  in  the  majority  of  cases  of  difficult  dentition,  yet  very  severe  symp- 
toms of  disturbance  of  the  ear  and  cerebral  circulation  may  apparently 
arise  in  these  cases.  The  symptoms,  of  course,  are  xery  varied,  the  most 
definite  ones  being  connected  ^^^th  the  ear.  In  this  class  of  cases  the 
gum  should  never  be  lanced,  even  for  the  purpose  of  bleeding,  as  the 
mouth  is  not  a  fit  place  for  such  a  procedure.  The  treatment  of  these 
cases  should  be  directed  to  the  especial  part  of  the  economy  from  which 
the  symptoms  arise.  For  instance,  if  the  ear  is  affected,  the  indication  is 
to  relieve  the  reflex  congestion.  This  can  be  done  by  the  instillation 
into  the  ear  of  a  few  drops  of  an  atropine  solution,  such  as  in  the  follow- 
ing prescription : 

PRESCEIPTIO^f    44. 

Metric.  Apothecary. 

Gramma. 


li    Atropinfe  sulphat 0 

Glvcerini, 


06         R    Atropinse  sulphat gr.  i ; 

Glvcerini, 

Aq.  de.stil aa  3175  Aq.  destil aa ^i. 

M.  M. 

Sig. — Drops  for  aural  conges'ion. 

In  addition  to  this,  bromide  of  potassium  or  sodium  should  be  given  in 
repeated  doses  to  the  extent  that  is  indicated  by  the  especial  case. 

In  Fig.  137  the  mucous  membrane  covering  the  crown  of  the  tooth  is 
shown  to  be  markedly  raised  above  the  level  of  the  gum.  In  these  cases, 
symptoms  of  local  origin  and  often  of  great  severity  arise.  The  infant 
evidently  has  extreme  pain  and  tenderness  in  its  mouth.     It  cries  inces- 


636 


PEDIATKICS. 


Pig.    138. 


santly,  and  often  refuses  to  take  its  nourishment,  on  account  of  the  acute 
pain  which  it  suffers,  and  also  of  the  tenderness  \vhich  is  produced  by  the 
least  pressure  on  the  gum,  so  that  it  may  become  weak 
and  exhausted.  There  is  usually  a  considerable  elevation 
of  the  temperature,  to  38.8°  C.  and  oven  39.4°  and  40°  C. 
(102°,  103°,  and  104°  F.).  Vomiting  is  not  uncommon, 
and  there  is  twitching  to  such  an  extent  that  co)ivulsions 
seem  to  be  threatening,  and  at  times  actually  occur. 
There  are  also  great  restlessness  and  insonniia. 

In  these  cases  lancing  the  gum  affords  immediate  re- 
lief. The  temperature  quickly  subsides,  the  pain  and 
general  nervous  symptoms  disappear,  and  the  infant  after 
sleeping  quietly  for  an  hour  or  so  wakes  up  and  takes 
its  food  with  avidity.  The  treatment  in  this  class  of  cases, 
when  the  diagnosis  is  once  made,  is  to  lance  the  gum. 
This  is  done  in  the  follomng  way.  The  infant  is  placed 
in  the  nurse's  lap,  with  its  head  in  the  lap  of  the  phy- 
sician, the  nurse  holding  its  arms  firmly.  The  physician, 
after  having  fir.st  thoroughly  sterilized  his  hands  and 
washed  the  infant's  mouth  and  gums  with  sterilized 
-water,  carefully  makes  an  incision  over  the  swollen  gum 
well  down  to  the  crown  of  the  tooth.  Fig.  138  represents 
the  gum-lancet  which  we  are  in  the  habit  of  using  for 
this  purpose.  As  only  the  end  of  this  lancet  is  sharp,  there  is  less  danger 
of  wounding  tlie  infant's  Jips  and  mouth  than  with  the  ordinary  bistoury. 
Before  using  the  lancet  it  should  be  thoroughly  sterilized. 

Although  much  has  been  said  about  the  danger  of  hemorrhage  in 
these  cases,  and  of  infection  of  the  wound  by  pathogenic  organisms,  yet 
instances  in  which  such  results  have  occurred  are  so  exceedingly  rare 
that  they  should  not  deter  us  from  treating  the  case  properly  as  we  would 
treat  an  abscess  in  the  mouth,  tonsil,  or  pharynx.  It  has  also  been  said 
that  a  cicatrix  may  form  on  the  gum  over  the  crown  of  the  tooth  as  a 
result  of  lancing.  This  is  an  exceedingly  rare  occurrence,  and  need 
scarcely  be  taken  into  account.  The  probability  is  that,  when  such  an 
instance  has  occurred,  the  case  was  not  one  in  which  the  gum  should  have 
been  lanced,  and  the  fear  of  such  a  result  as  this  should  certainly  not 
weigh  in  the  balance  against  the  possible  exhaustion  and  acute  pain 
which  may  continue  for  days  unless  relief  is  given  by  cutting. 

It  must  be  understood,  however,  that  the  first  class  of  cases  of  difficult 
dentition  are  by  far  the  most  frequent. 
The  following'  case  is  illustrative  : 


Giim-]ancet. 


An  infant,  ten  months  old,  was  brought  to  the  clinic  with  the  following  history  : 
It  had  one  lower  incisor.     At  the  time  when  this  tooth  was  about  to  appear  above 
the  margin  of  the  gum  the  infant  was  very  restless,  and  had  considerable  fever,  and 
pain  in  its  ear.     Somewhat  later  a'  muco-purulent  discharge  came  from  the  ear,  but 


DISEASES    OF   THE   MOUTH.  637 

Uie  general  symptoms  of  restlessness,  pain  at  times,  and  the  local  symptoms  of  heat 
and  irritation  in  the  mouth  continued  until  just  before  the  tooth  had  pierced  the  gum. 
After  that  time  the  discharge  from  the  ear  ceased,  and  the  infant  became  perfectly  well, 
the  local  irritation  also  having  disappeared. 

Three  or  four  days  previous  to  being  seen  at  the  clinic  the  same  symptoms  re- 
turned. The  infant  was  evidently  sutTering  from  irritation  in  its  mouth.  Sometimes 
the  gums  were  hot  and  dry,  and  again  there  was  a  hypersecretion  of  saliva.  It  con- 
tinually put  its  finger  to  the  gum  of  the  lower  jaAV,  sometimes  almost  locating  it  near 
the  place  where  the  first  tooth  was  cut.  The  ear  had  begun  to  discharge  again,  and 
the  infant  showed  signs  of  general  discomfort  by  rubbing  its  nose  and  head  continu- 
ally and  at  times  crying  out  as  though  in  pain. 

Gn  examining  the  gum  it  was  found  to  be  swollen,  but  there  was  no  especially 
tender  point.  On  examining  the  ears  an  old  perforation  of  the  membrana  tympani 
A'/as  found  in  the  right  ear,  which  was  discharging,  while  in  the  left  ear  there  was  a 
simple  congestion. 

Such  cases  as  this  are  often  treated  by  lancing  the  gum,  yet  this  procedure  is  not 
of  the  slightest  use,  and  is,  in  fact,  contraindicated,  as  it  will  only  increase  the  already 
existing  irritation  of  the  mouth.  The  treatment  should  be  the  internal  administration 
of  bromide  of  potassium  and  appropriate  local  treatment  for  the  ear. 

The  other  cases  are  so  smiilar  and  are  so  commonly  met  with  that 
we  need  not  dweU  upon  them,  but  shaU  report  one  of  the  cases  in  which 
lancing  of  the  gum  is  indicated. 

An  infant,  eight  months  old,  and  in  good  health,  cut  its  firbl  tooth  when  it  was 
seven  months  old.  At  this  time  there  were  no  nervous  disturbances,  the  tooth  coming 
through  the  gum  without  any  reflex  or  local  symptoms  whatever. 

When  the  second  tooth  was  pressing  on  the  gum  we  were  called  to  relieve  the  fol- 
lowing symptoms.  The  infant,  who  had  been  perfectly  well,  and  who  on  examination 
showed  no  disease  of  any  organ,  was  reported  to  have  been  feverish,  restless,  and 
crying  out  with  pain  for  the  previous  twenty-four  hours.  It  had  refused  to  nurse, 
had  not  slept  for  thirty-six  hours,  had  vomited  a  number  of  times,  and  was  found  to 
have  a  temperature  of  40°  C.  (104°  F.).  It  twitched  from  time  to  time,  and  appar- 
ently was  in  danger  of  having  general  convulsions.  On  examining  the  mouth  one  of 
I  he  lower  middle  incisors  was  found  to  be  entii'ely  through  ths  gum.  The  gum  next 
to  this  incisor  was  greatly  swollen,  tense,  cartilaginous  in  feeling,  hot,  and  tender,  so 
that  whenever  it  was  tauched  the  infant  screamed  with  pain.  We  then  lanced  the  gum. 
Tlie  expression  of  pain,  which  had  been  marked  on  the  infant's  face,  disappeared  im- 
uiediately,  and  was  replaced  by  an  expression  of  tranquillity,  and  it  was  evident  that 
the  severe  pain  had  Ijeen  relieved  instantaneously.  The  infant  went  to  sleep  at  once, 
and  slept  two  hours.  When  it  awoke  its  temperature  was  normal,  it  took  the  breast 
with  great  eagerness,  and  from  that  time  it  had  no  more  trouble  in  its  mouth.  All  the 
rest  of  its  teeth  were  cut  without  any  abnormal  symptoms. 

The  following  case  illustrates  to  a  still  greater  extent  the  necessity  of 
lancing  the  gums  in  certain  cases. 

'  An  infant  began  to  have  irritation  from  its  teeth  when  it  was  five  months  old.  At 
this  time  it  woke  up  in  the  night  screaming,  and  continued  to  scream  with  pain  for 
several  hours,  during  which  time  its  parents  had  to  walk  continually  up  and  down 
the  room  with  it.  Various  remedies  were  administered,  but  without  the  slightest 
relief,  and  finally,  after  two  days  of  sutTering,  in  Avhich  it  refused  to  take  its  nourisii- 


638  PEDIATRICS. 

ment,  it  lost  in  weight,  and  seemed  very  ill.     An  incision  was  made  over  the  hot  and 
swollen  gum,  with  immediate  relief. 

The  same  symptoms  occurred  when  the  next  tooth  appeared  heneath  the  surface 
of  the  gum,  but  were  relieved,  after  waiting  for  a  few  hours,  by  lancing.  Of  the  re- 
maining eighteen  teeth,  six  or  eight  gave  rise  to  similar  symptoms,  but  in  every  instance 
immediate  relief  was  afforded  by  the  lancing  of  the  gum. 

DISEASES  OF  THE  NOSE. 

The  nose  is  the  normal  passage  for  the  entrance  of  air  to  the  lungs, 
and  it  is  principally  here  that  the  air  is  modified  before  entering  them. 
In  normal  respiration  the  mucous  membrane  of  the  nasal  cavities,  on 
account  of  the  peculiar  shape  of  the  turbinated  bones,  presents  a  large 
surface  to  the  inspired  air,  and  is  therefore  admirably  adapted  to  filter  it 
of  particles  of  dust  and  micro-organisms.  The  air  is  also  warmed  and 
changed  so  that  before  it  reaches  the  larynx  it  is  saturated  with  moisture 
and  heated  to  a  temperature  of  35°  C.  (95°  F.).  This  modification  of 
the  air  is  especially  important  in  the  new-born,  since  the  lung  has  so 
lately  been  brought  into  use  and  is  in  such  a  comparatively  undeveloped 
condition  that  it  cannot  withstand  unchanged  air,  to  which  it  adapts  itself 
better  later  in  life.  The  passage  through  which  the  air  passes  in  going  to 
and  through  the  naso-pharynx  is  extremely  narrow  in  young  infants,  and 
can  easily  become  occluded.  There  are  not  many  diseases  which  occur 
in  the  nose  in  infants  .and  young  children,  and  those  which  we  do  find 
are  serious  chiefly  by  being  the  cause  of  occlusion.  In  case  of  mouth- 
breathing  due  to  nasal  occlusion  in  an  infant,  the  air  which  has  not  been 
modified  by  passing  through  the  nose  and  naso-pharynx  may  have  a  detri- 
mental influence  on  the  lung  and  general  circulation,  thus  striking  a  serious 
blow  at  the  infant's  vitality.  In  later  childhood,  although  the  occlusion 
which  arises  in  the  nares  may  not  be  so  serious  as  regards  the  life  of  the 
patient,  yet  the  results  of  such  a  condition  will  be  represented  by  retarded 
development  of  the  child  and  interference  with  the  function  of  hearing, 
with  resulting  mental  dulness. 

RHINITIS. 

The  most  common  pathological  condition  which  occurs  in  the  nose  in 
infancy  and  childhood  is  some  form  of  rhinitis.  This  may  be  acute  or 
chronic,  catarrhal  or  purulent,  hypertrophic  or  atrophic.  New  growths 
are  rare.  Of  these  the  more  common  is  myxoma  or  simple  mucous 
polypus. 

Acute  Rhinitis. — Acute  rhinitis  (acute  coryza)  is  an  inflammation 
of  the  mucous  membrane  of  the  nasal  cavities. 

Etiology, — The  cause  of  the  disease  in  most  cases  is  apparently  undue 
exposure  to  cold,  though  it  may  be  proved  eventually  that  this  exposure 
merely  prepares  the  way  for  the  attack  of  some  micro-organism.  The 
frecjuency  with  which  a  cold  in  the  head  follows  a  similar  condition  in  an 
attendant  or  a  companion,  suggests  strongly  a  direct  infection.     This  con- 


DISEASES    OF    THE    NOSE.  639 

dilion  may  in  almost  all  cases  be  considered  as  part  of  a  disease  which 
affects  the  mucous  membrane  of  the  naso-pharynx  as  well  as  of  the  nares. 

Symptoms. — The  symptoms  are  a  sense  of  fulness,  burning,  and  dryness 
in  the  nostrils,  succeeded  in  a  few  hours  by  a  serous  discharge,  which 
later  becomes  muco-purulent.  There  is  usually  a  slight  rise  of  tempera- 
ture, and,  although  the  general  symptoms  are  often  slight,  there  is  com- 
monly a  very  evident  sense  of  discomfort,  with  loss  of  appetite  and  general 
malaise.  In  some  cases,  by  direct  extension  of  the  inflammation  through 
the  Eustachian  tube,  an  otitis  media  may  be  caused.  The  entrance  of  air 
into  the  naso-pharynx  is  blocked  by  the  swelling  of  the  erectile  tissues 
covering  the  turbinate  bones,  and  almost  complete  occlusion  takes  place. 
The  patient  is  then  forced  to  breathe  with  the  mouth  open,  and  a  result- 
ing condition  of  dryness  of  the  mucous  membrane  of  the  mouth  and 
throat  and  a  choking  sensation  arising  from  it  follow.  The  natural  ten- 
dency of  an  infant  or  young  child  is  to  keep  the  mouth  shut,  so  that  often 
when  the  nose  is  occluded  it  breathes  with  great  difficulty  when  asleep, 
and  its  face  becomes  congested  and  even  cyanotic.  On  forcing  the  mouth 
open  the  symptoms  of  congestion  and  cyanosis  disappear,  and  the  child 
begins  to  snore,  and  breathes  with  comparative  comfort  so  long  as  its 
mouth  remains  open,  until  the  dryness  of  the  throat  wakes  it  up. 

Prognosis. — The  prognosis  in  these  cases  of  acute  rhinitis  is  usually 
good.  The  disease  runs  its  course  in  a  variable  period  of  from  three  days 
to  a  week,  and,  unless  the  child  is  subjected  to  fresh  exposure,  it  recovers 
entirely.  The  prognosis,  however,  varies  in  accordance  with  the  age  of  the 
individual  attacked.  The  danger  that  a  young  debilitated  infant  may  die 
from  exhaustion  when  the  nares  are  occluded  is  considerable,  and  we  have 
seen  a  puny,  ill-cared-for  infant  die  of  a  simple  acute  rhinitis  with  occlusion. 
Instances  of  this  kind  should  warn  us  that  active  treatment  is  indicated. 

Treatment. — The  treatment  should  be  directed  primarily  to  relieving 
the  nasal  occlusion.  This  is  best  accomplished  by  atomizing  the  nose. 
In  most  cases  the  oil  atomizer  containing  oleum  petrolatum  album  is 
sufficient  to  afford  relief.  In  addition  to  the  local  treatment,  the  adminis- 
tration of  stimulants  is  indicated  when  there  is  exhaustion.  Care  should 
be  taken  that  the  infant  is  taking  a  sufficient  amount  of  nourishment. 
This  is  especially  difficult  to  determine  if  it  is  nursing,  as  under  these 
circumstances  it  will  often  hold  the  nipple  in  iLs  mouth  and  apparently 
suck,  while  its  breathing  is  so  much  disturbed  by  the  nasal  obstruction 
that  it  does  not  draw  much  milk  from  the  breast.  The  various  drugs 
which  have  been  recommended  for  acute  rhinitis  have  not  in  our  hands 
proved  to  be  of  much  use.  We  have  occasionally  found  that  ten  drops 
of  the  tincture  of  euphrasia  repeated  three  or  four  times  at  intervals  of 
an  hour  will  seemingly  lessen  the  nasal  secretion. 

An  instance  of  this  class  is  the  case  of  an  infant  who  had  an  attack  of  acute 
rhinitis  wlien  she  was  four  months  old.  Altliough  she  was  well  nourished  and  fairly 
strong,    yet  the  occlusion  of   the  nares,   which  took  place  rapidly,  produced  serious 


fi40  PEDIATRICS. 

symptoms.  She  was  somewhat  cyanotic,  refused  to  take  her  food,  which  had  in  tiq 
forced  down  her  throat,  and  was  sleepless,  while  her  strength  failed  rapidly.  She  was 
cared  for  hy  a  trained  nurse  night  and  day,  the  oil  spray  was  used  at  frequent  intervals, 
and  stimulants  were  given,  with  the  inhalation  of  oxygen  once  every  three  or  four 
hours.     Under  this  treatment  she  improved  slowly  and  recovered  entirely. 

In  older  children  the  serious  symptoms  just  described  do  not  occur, 
as  a  rule,  and  the  disease  is  not  much  more  significant  than  the  coryza 
of  the  adult. 

Purulent  Rhinitis. — A  rather  rare  form  of  rhinitis  is  at  times  met  Avith, 
in  which  the  discharge  is  essentially  purulent.  It  is  subacute  or  chronic 
in  character,  and  is  generally  associated  with  unhealthy  surroundings  and 
some  constitutional  weakness.  The  possibility  of  nasal  dii)litheria  should 
always  be  borne  in  mind  in  these  cases,  especially  when  the  dls;  harge  is 
mixed  with  blood.  In  these  cases  the  secretions  should  be  examined  for 
the  Klebs-Loeffler  bacillus. 

Etiology. — In  these  cases  of  purulent  rhinitis  a  purulent  discharge 
from  the  nose  may  be  the  result  of  an  unsuspected  foreign  body  in  the 
nasal  passag-es.  This  is  especially  likely  to  be  the  case  if  the  discharge  is 
from  one  side  only.  It  frequently  occurs  in  children,  as  they  are  very 
apt  to  push  various  bodies  up  their  noses.  If  the  foreign  body  happens 
to  be  a  piece  of  thin  paper  or  other  soft  material,  it  may  not  cause  much 
nasal  obstruction,  and  its  presence  may  easily  be  overlooked  even  when  a 
probe  is  carefully  used  in  making  the  examination.  This  form  of  rhinitis 
is  not  accompanied  by  any  especial  enlargement  of  the  turbinate  bones, 
and  narrowing  of  the  nasal  passages  is  not  a  prominent  symptom. 

Symptoms. — The  symptoms  are  chiefly  a  purulent  discharge  from  the 
nostrils,  and  redness  and  excoriation  produced  by  the  acrid  character  of 
the  discharge. 

Prognosis. — The  prognosis  of  purulent  rhinitis  is  good,  except  in  ex- 
tremely debilitated  cliildren. 

Treatment. — The  treatment  consists  in  cleanliness,  especial  attention 
being  paid  to  cleansing  the  nares  with  alkaline  solutions,  and  in  attention 
to  the  general  healtli. 

Hypertrophic  Rhinitis. — This  form  of  rliiiiilis  is  rare  hi  infancy  and 
childhood,  and  we  shall  therefore  merely  refer  to  it.  Rhinitis  is  spoken  of 
as  hypertrophic  when  in  addition  to  a  chronic  inflammation  of  the  mucous 
and  submucous  tissues  of  the  nose  there  is  an  actual  hypertrophy  of  the 
mucous  membrane,  which  residts  in  occlusion  of  the  nares  and  conse- 
quent interference  with  respiration  and  with  the  removal  of  the  normal 
discharges  from  the  nose. 

Etiology. — One  of  the  most  common  causes  of  hypertrophic  rhinitis 
is  the  occlusion  of  the  posterior  nares  by  adenoid  growths,  which  inter- 
fere with  the  normal  nasal  secretions  by  retaining  them  in  the  nasal  cavity 
and  allowing  them  to  decompose.  A  recurrent  acute  rhinitis  may  also  be 
an  etiological  factor  in  hypertrophic  rhinitis. 


DISEASES   OF   THE   NOSE.  641 

Symptoms. — The  most  marked  symptoms  in  hypertrophic  rhinitis  is  the 
nasal  obstruction,  which  usually  alternates  from  one  side  of  the  nose  to  the 
other.  As  would  naturally  be  expected  from  the  lesions,  the  symptoms  are 
those  of  restlessness,  especially  at  night,  and  various  reflex  phenomena 
connected  with  the  throat  and  the  larynx.  Thus,  there  may  be  continued 
cough,  and,  when  the  Eustachian  tubes  are  occluded,  deafness  and  a  re- 
sulting hebetude.  At  times  interference  with  speech  results.  There  is  not 
much  nasal  secretion  in  these  cases,  which  aids  us  in  the  differential  diag- 
nosis from  the  other  forms  of  rhinitis  which  have  just  been  mentioned. 

Treatment. — The  treatment  of  these  cases,  when  they  are  dependent 
upon  growths  in  the  naso-pharynx  is  the  surgical  removal  of  such 
growths.  Mild  astringent  sprays  should  be  used,  and  the  oleum  petrola- 
tum spray  recommended  in  catarrhal  rhinitis.  As  a  rule,  these  cases 
should  be  placed  in  the  hands  of  a  specialist. 

Atrophic  Rhinitis  {ozmna). — By  atrophic  rhinitis  is  meant  a  condition  of 
the  nose  characterized  by  atrophy  of  the  mucous  membrane  and  of  the 
bony  prominences  Avithinthe  nose,  accompanied  by  what  has  been  termed 
a  dry  catarrh,  as  a  result  of  which  the  secretion  of  the  nose  forms  crusts, 
which  undergo  decomposition  and  become  fetid.     It  is  also  called  ozsena. 

Etiology. — The  disease  is  one  which  attacks  older  children  rather 
than  infants,  and  its  etiology  is  obscure.  The  glandular  function  is  im- 
paired, and  the  muco-purulent  discharge  becomes  thick  and  firmly  adhe- 
rent in  the  form  of  crusts  to  the  sinuosities  of  the  nose.  This  film  of 
desiccated  muco-pus  in  drying  contracts  the  underlying  turbinated  tissues 
in  such  a  way  as  to  interfere  with  the  circulation  of  the  blood,  a  condition 
which  limits  glandular  action  still  more  and  conduces  to  general  atrophy. 

Symptoms. — The  symptoms  of  atrophic  rhinitis  are  the  formation  of 
crusts  and  the  presence  of  fetor. 

Treatment. — Although  the  tissues  which  have  actually  been  destroyed 
by  the  atrophic  process  cannot  be  restored  by  treatment,  the  patient  can 
be  entirely  relieved  of  the  crust  formation  and  fetor  by  persistent  and 
patient  local  washing  and  applications.  The  details  of  treatment  differ 
according  to  the  extent  and  character  of  the  disease.  Crusts  may  be 
removed  by  spraying  or  douching,  great  care  being  taken  to  prevent  the 
washing  fluid  from  entering  the  Eustachian  tubes.  If  this  is  not  sufficient 
to  remove  the  crusts,  the  nasal  cavities  must  be  illuminated  with  a  head- 
mirror,  and  the  crusts  carefully  brushed  off  with  a  cotton-stick.  The 
formation  of  dry,  hard  crusts  is  often  prevented  by  frequent  spraying 
with  an  oil.  Local  applications  of  different  substances  are  of  use  in 
many  cases,  but  these  should,  as  a  rule,  be  carried  out  under  the  direc- 
tion of  a  specialist  in  the  treatment  of  diseases  of  the  nose, 

MUCOUS    POLYPUS. 

This  is  a  pedunculated  connective-tissue  growth  originating  from  the 
mucous  membrane  of  the  middle  turbinate  bone.     It  is  rare  in  children. 

41 


642  PEDIATRICS. 

It  does  not  grow  on  a  healthy  mucous  membrane,  and  is  always  preceded 
by  some  morbid  condition  of  the  nose.     It  is  often  multiple. 

The  symptoms  begin  with  a  nasal  discharge  followed  by  nasal  occlu- 
sion. The  diagnosis  is  easily  made  by  a  mirror  and  a  probe.  The  treat- 
ment is  the  removal  of  the  growth. 

EPISTAXIS. 

During  the  period  of  early  childhood  epistaxis,  or  hemorrhage  from 
the  nose,  is  not  uncommon.  We  have  occasionally  met  with  epistaxis  in 
young  infants,  but  in  our  experience  it  is  rare  in  the  early  months  of  life. 
In  older  children  recurrent  epistaxis,  especially  if  unilateral,  points  to  the 
presence  of  an  erosion  or  a  varicose  condition  in  the  cartilaginous  septum 
near  the  external  opening  of  the  nose. 

Unless  the  individual  happens  to  be  affected  by  hgemophilia,  epistaxis 
is  not  especially  dangerous,  and  usually  its  occurrence  ceases  as  the  child 
grows  older. 

Treatment. — The  application  of  pressure  on  the  side  of  the  base  of 
the  nose  and  the  use  of  ice  are  usually  sufficient  to  stop  the  hemorrhage. 
If  the  epistaxis  is  due  to  the  varicose  condition  just  spoken  of,  it  can  be 
readily  controlled  temporarily  by  a  plug  of  cotton  pressed  upon  the  bleed- 
ing part.  For  a  permanent  cure,  cauterizing  the  bleeding  part  may  be 
necessary. 

DISEASES  OF   THE  EAR. 

It  is  very  important  to  bear  in  mind,  m  examining  infants  and  children, 
the  common  occurrence  of  some  morbid  process  in  the  ear.  In  many 
cases  in  which  the  more  pronounced  aural  symptoms  are  not  evident, 
symptoms  which  appear  obscure,  but  really  are  due  to  some  latent  dis- 
turbance in  the  neighborhood  of  the  ear,  reflex  or  otherwise,  are  readily 
explained  when  in  addition  to  tlie  presence  of  some  other  disease  the 
unusual  symptoms  are  found  to  arise  from  the  aural  complication.  The 
question  of  diseases  of  the  ear  m  infancy  and  childhood  has  not  received 
-from  the  general  practitioner,  nor,  indeed,  from  those  who  devote  them- 
selves especially  to  children,  the  attention  that  it  deserves.  Even  leaving 
out  of  consideration  the  cases  of  disease  of  the  middle  ear  incident  to 
the  exanthemata,  serious  implications  of  the  ear  from  other  causes  are  not 
uncommon  during  the  first  year  of  life,  and  we  should  especially  watch 
for  an  aural  complication  in  pneumonia. 

Von  Troltsch  found  on  examining  forty-seven  petrous  bones  taken 
from  twenty-four  unselected  children  that  the  middle  ear  was  normal  in 
only  eighteen.  The  -other  twenty-nine  ears  showed  in  varying  degrees 
the  appearance  of  a  purulent  and  sometimes,  though  rarely,  of  a  mucous 
catarrh.  Of  the  fifteen  children  with  exudation  in  the  middle  ear,  the 
youngest  was  three  days  and  the  oldest  one  year  old ;  five  were  in  their 
first  month,  two  each  in  their  second  and  fourth,  three  in  their  third,  and 
Qiie  each  in  their  seventh,  eighth,  and  twelfth  months. 


DISEASES    OF    THE    EAR.  643 

In  every  five  examinations  of  the  ears  of  new-born  children  Schwartze 
found  the  tympanum  filled  with  pus  in  two. 

Wreden  found  in  eighty  ears  of  children  a  normal  middle  ear  in  only 
fourteen  ;  purulent  catarrh  existed  in  thirty-six,  and  simple  mucous  catarrh 
in  thirty  ;  the  youngest  child  had  lived  twelve  hours,  the  oldest  fourteen 
months.  The  majority  of  these  cases  were,  however,  from  three  to 
fourteen  days  old. 

Edward  Hoffman  examined  twenty-four  petrous  bones  in  infants  vary- 
ing in  age  from  thirty-two  hours  to  four  weeks,  and  found  the  tympanum 
filled  with  pus  in  seven  cases. 

Of  two  hundred  and  thirty  carefully  examined  cases  under  seven 
months  of  age  Kutcharianz  found  the  tympanic  mucous  membrane  normal 
in  thirty  only.  In  fifty  it  showed  either  slight  or  intense  catarrhal  inflam- 
mation, and  in  one  hundred  and  fifty  the  tympana  were  filled  with  pus. 

These  statistics,  quoted  from  Von  Troltsch,  serve  to  emphasize  the 
statements  of  that  author  that  even  from  the  beginning  of  extra-uterine 
life  "there  is  an  unusually  strong  disposition  to  disease  of  the  middle 
ear,  owing  on  the  one  hand  to  the  double  influence  of  the  peculiar 
morphological  relations  of  the  ear  and  the  pharynx,  and  on  the  other 
hand  to  the  diseases  and  conditions  of  life  to  which  the  child  is  frequently 
exposed." 

It  has  been  noted  that  in  cases  of  pneumonia  occurring  in  children 
infection  of  the  ear  is  not  common  if  the  naso-pharynx  is  free  from  ade- 
noids ;  otherwise  it  is  a  frequent  complication.  Middle-ear  infections 
occur  in  80  per  cent,  of  cases  of  pneumonia  (Crockett),  while  in  measles 
and  typhoid  fever  the  percentage  is  only  about  10. 

In  the  middle-ear  infections  in  typhoid  and  diphtheria  cultures  have 
shown  the  continiied  presence  of  organisms  for  eight  or  nine  months.  In 
these  diseases,  therefore,  the  aural  discharges  may  be  a  source  of  danger 
even  afLer  the  symptoms  have  subsided.  In  these  cases  there  is  usually  a 
mixed  infection. 

In  the  first  twelve  or  eighteen  months  of  life  the  ear  symptoms  are 
elusive.  There  may  be  no  symptoms  suggesting  middle-ear  infection 
other  than  the  general  signs  and  symptoms  of  sepsis,  and  meningeal  irri- 
tation, such  as  twitching,  rigidity  of  the  neck,  retraction  of  the  head,  and 
convulsive  movements  of  the  extremities.  In  older  children  the  pain 
may  be  referred  to  the  stomach.  If  the  upper  posterior  w^all  of  the  canal 
is  reddened  it  points  towards  a  tubercular  meningitis  (Blake). 

These  pathological  and  clinical  observations  emphasize  the  fact  that 
the  ear  in  children  is  a  very  frequent  source  of  infection  by  a  number  of 
pathogenic  organisms,  such  as  the  pneumococcus  and  streptococcus,  and 
that  this  infection,  although  frequently  primary,  is  usually  secondary  to 
infection  elsewhere,  as  from  the  cerebral  meninges  and  especially  from 
the  naso-pharynx. 

We  should  therefore  consider  carefully  the  ear  in  all  cases  in  which 


644  PEDIATRICS. 

the  symptoms  are  obscure,  as  well  as  in  those  diseases  in  which  it  is  well 
known  that  aural  complications  are  liable  to  arise.  For  the  treatment  of 
acute  otitis  media,  see  page  566. 

DISEASES   OF   THE   NASO-PHARYNX. 

Although  the  ca^'ity  of  the  naso-pharynx  is  small  and  apparently  in- 
significant, yet  it  plays  a  very  important  part  in  a  number  of  the  diseases 
to  which  children  are  susceptible.  The  condition  which  makes  this  por- 
tion of  the  respirator}'  tract  especially  important  is  the  presence  of  the 
pharyngeal  tonsil  which  Imes  its  cavity. 

HYPERTROPHY   OF   THE  PHARYNGEAL.  TONSIL   (Adenoid 

Growths). 

The  glandular  or  lymph-tissue  which  lines  the  vault  and  posterior 
wall  of  the  naso-pharynx  is  very  similar  to  that  which  composes  the 
faucial  tonsils,  and  is  called  the  pharyngeal,  third,  or  Luschka's  tonsil. 
Under  certam  circumstances  this  tissue  becomes  hypertrophied,  and  gives 
rise  to  the  condition  wliich  is  usually  designated  as  adenoid  growths. 

Etiology. — The  pharj^ngeal  tonsils,  like  the  faucial  tonsils,  are  normal 
structures,  and  become  pathological  only  when  they  are  hypertrophied 
or  diseased.  Careful  exammation  will  reveal  the  presence  of  hypertrophy 
in  the  majority  of  children,  but  in  normal  cases  it  is  small  and  produces 
no  symptoms.  Although  h}T3ertrophy  of  the  pharyngeal  tonsil  may  occur 
in  infancy,  it  is  uncommon  before  the  second  or  third  year.  The  disease  is 
essentially  one  of  childhood,  as  it  very  seldom  develops  after  puberty. 
Acute  inflammatorj^  conditions  or  some  obstruction  in  the  nose  are  prob- 
ably the  incitmg  causes  of  the  hypertrophy. 

Pathological  Anatomy. — The  pathological  condition  which  is  found  in 
the  lymph-tissues  of  the  naso-pharynx  is  an  hypertrophy  which  is  very 
similar  to  the  hypertrophic  condition  of  the  faucial  tonsils,  except  that 
the  latter  contains  a  greater  amount  of  connective  fibrous  tissue.  The 
/^  hypertrophy  may  be  of  greater  or  less  extent,  sometimes  not  being  suffi- 
cient to  cause  any  especial  occlusion  and  at  other  times  completely  occlud- 
ing the  posterior  nares. 

Symptoms. — ^The  most  promment  symptom  noticed  in  children  who 
have  this  disease  is  that  they  breathe  with  their  mouths  open  at  night  and 
snore.  As  the  nares  become  more  occluded  the  child  begins  to  breathe 
through  its  mouth  also  when  it  is  awake.  The  interference  mth  the 
proper  passage  of  the  air  to  the  larynx  and  lung  results  in  a  chronic  form 
of  pharyngitis  and  laryngitis,  while  the  blocking  of  the  nasal  end  of  the 
Eustachian  tubes  may  result  in  a  chronic  catarrhal  condition  of  the  middle 
ear.  Any  or  all  of  these  symptoms  may  arise  in  an  individual  case 
according  to  the  amount  or  position  of  the  obstruction.  The  child's  ex- 
pression changes,  and  is  almost  characteristic  when  the  disease  is  fully 
developed.     It  holds  its  mouth  open,  and  the  lower  jaw  appears  to  drop, 


DISEASES   OF   THE   NASO-PHARYNX.  645 

giving  it  a  stupid  look.  If  this  condition  continues  after  the  seventh  or 
eighth  year,  the  bridge  of  the  nose  is  apt  to  be  prominent  and  its  sides  to 
look  pinched ;  the  palate  may  be  markedly  arched,  and  the  upper  jaw 
narrowed  laterally  so  as  to  crowd  the  teeth.  The  fauciai  tonsils  may  or 
may  not  be  enlarged,  but  are  usually  so.  Another  symptom  is  an  in- 
creased liability  to  attacks  of  acute  rhinitis,  and  a  tendency  for  these 
attacks  to  become  subacute  or  chronic. 

Lack  of  development  of  the  chest  with  flattening  of  the  front  of  the 
thorax  may  be  caused,  not,  as  was  formerly  supposed,  by  the  enlargement 
of  the  fauciai  tonsils,  but  by  the  occlusion  caused  by  the  hypertrophy  of 
the  pharyngeal  tonsil.  This  hypertrophy  with  its  resulting  nasal  occlusion 
may  also  be  the  cause  of  pharyngitis,  laryngitis,  and  perhaps  of  bronchial 
catarrh  or  asthma,  which  can  be  cured  only  by  the  removal  of  the  primary 
cause,  the  pharyngeal  tonsil. 

Diagnosis. — The  diagnosis  of  hypertrophy  of  the  pharyngeal  tonsil  is 
not  difficult  in  a  ms^rked  case  or  if  it  is  possible  to  examine  the  child's 
naso-pharynx.  In  young  infants  the  posterior  nasal  space  is  so  minute 
that  it  is  almost  impossible  to  reach  it.  The  diagnosis  can  often  be  made 
simply  by  the  appearance  of  the  child,  as  there  is  no  other  disease  which 
especially  simulates  this  condition.  A  definite  diagnosis,  however,  can  be 
made  only  after  the  hypertrophied  tonsil  has  actually  been  seen  or  felt. 

The  importance  of  learning  to  detect  by  means  of  the  finger  the  pres- 
ence of  an  enlarged  pharyngeal  tonsil  is  great.  If  an  examination  with  the 
posterior  rhinoscopic  mirror  can  be  made  the  exact  extent  of  the  hyper- 
trophy can  be  seen,  and  the  child  spared  the  discomfort  of  a  digital  exami- 
nation, but  the  examination  with  the  mirror  in  the  throat  is  usually  so 
difficult  in  young  children  that  the  direct  detection  by  means  of  the  finger 
is  often  the  best  method.  The  child  should  have  a  blanket  pinned 
around  it  tightly,  so  as  to  keep  it  from  moving  its  arms.  It  should  be 
held  firmly  sitting  in  the  nurse's  lap.  The  child's  head  is  then  held 
with  one  arm,  pressing  the  cheek  between  the  back  teeth  with  the  fore- 
finger, then  passing  the  forefinger  of  the  other  hand  gently,  firmly,  and 
quickly  over  the  base  of  the  tongue  and  behind  the  soft  palate  until  it 
reaches  the  posterior  wall  of  the  pharynx.  By  quickly  turning  the  finger 
upward,  it  is  easy  to  feel  whether  the  cavity  of  the  naso-pharynx  is 
clear  or  whether  it  is  more  or  less  filled  by  a  soft,  spongy  mass,  the  hyper- 
trophied pharyngeal  tonsil.  There  is  usually  a  little  blood  on  the  finger 
when  it  is  withdrawn,  as  the  growth  is  friable  and  bleeds  easily.  This 
examination  is  not,  as  a  rule,  very  painful  to  the  child,  but  is  in  many 
cases  very  disagreeable  and  alarming  to  it.  When  the  finger  is  once  in 
the  mouth,  it  is  not  wise  to  take  it  out  again  until  the  examination  is  com- 
pleted, as  the  child  can  rarely  be  induced  to  allow  a  second  attempt  to 
be  made.  In  passing  the  finger  over  the  base  of  the  tongue  it  is  necessary 
to  be  careful  to  get  the  finger  behind  the  soft  palate,  and  not  to  push  it 
upward  and  backward,  for  in  this  case  the  soft  tissues  of  the  palate  may 


646 


PEDIATRICS. 


feel  like  an  adenoid  growth.  The  child  can  be  prevented  from  biting  the 
finger  by  simply  keeping  the  cheek  pressed  between  the  teeth  as  has  just 
been  described. 

Another  valuable  sign  of  adenoids  in  children  is  that  described  by 
Goodale.  It  is  shown  by  the  deficient  retraction  of  the  soft  palate  when 
the  child  is  made  to  gag.  In  the  presence  of  an  excessive  amount  of 
adenoid  tissue  there  is  a  considerable  space  separating  the  uvula  from  the 
posterior  pharyngeal  wall  and  a  flattening  of  the  vault  of  the  soft  palate. 

Fig.  139,  page  646,  represents  the  typical  picture  of  an  adenoid  growth  in  a  girl 
ten  years  old.  She  held  her  month  open  and  evidently  had  complete  occlusion  of  the 
posterior  nares,  the  anterior  nares  on  examination  heing  found  entirely  free.  The 
pinched  look  of  the  face  on  either  side  of  the  nose  and  the  prominence  of  the  bridge 
of  the  nose  are  to  be  noticed.     The  child  was  dull,  the  dulness  having  increased  as 


Fig.  139. 

-  -k'-^"'^ 

1 

J»v, 

i 

1 

Hypertrophy  of  pharyngeal  tonsil  (adenoid  growths),    iemaie,  10  years  old. 


le  other  symptoms  of  the  adenoid  growth  developed,  and  her  face  had  a  stupid  ex- 
pression. On  examining  the  child's  mouth  the  hard  palate  was  found  to  be  very  much 
arched,  the  tonsils  were  enlarged,  and  the  soft  palate  was  slightly  pushed  forward,  the 
pharynx  being  narrower  than  normal. 

After  removal  of  the  adenoid  gi'owth  and  faucial  tonsils  she  found  no  difficulty  in 
keeping  the  mouth  closed,  not  only  while  awake,  but  also  at  night,  and  slept  much 
more  quietly  than  before.  Her  general  health  imjjroved,  and  the  development  of  her 
face  during  the  remainder  of  its  growth  was  normal. 


Although  the  symptoms  of  adenoids  cannot  be  overlooked  in  typical 
cases,  we  must  recognize  the  fact  that  many  children  may  have  a  large 
growth  of  adenoids  without  giving  rise  to  mouth-breathing,  snoring  or 
other  evidences  of  nasal  obstruction.  This  is  due  probably  to  the  pecu- 
liarity of  the  situation  of  the  growth,  or  to  the  fact  that  the  vault  of  the 
naso-pharynx  is  large  enough  to  accommodate  it  without  interference  in 
the  breathing.     Such  cases  are  much  less  likely  to  need  operation,  but  oc- 


DISEASES   OF  THE  NASO-PHARYNX.  647 

casionally  one  meets  with  obscure  cases  of  malnutrition,  anorexia  and 
anaemia  which  resists  all  method  of  treatment  until  the  removal  of  the 
adenoid.  We  have  seen  general  striking  examples  of  this  class  of  cases. 
If  therefore  in  any  obscure  case  of  debility  we  find  on  examination 
adenoid  vegetations  present  to  a  considerable  degree,  we  are  in  the  habit 
of  recommending  their  removal  even  though  there  are  no  symptoms  of 
obstruction. 

Prognosis. — The  prognosis  of  cases  of  hypertrophy  of  the  pharyngeal 
tonsil  varies  greatly,  for  there  are  all  forms  and  degrees  of  the  affection. 
In  some  cases  the  swelling  of  the  lymph-tissues  occurs  only  at  intervals 
when  the  child  had  been  subjected  to  exposure  in  inclement  weather; 
it  will  then  show  itself  simply  by  occlusion  of  the  nares,  with  resulting 
discomfort,  lasting  for  some  weeks,  but  disappearing  eventually  as  the 
weather  becomes  milder  or  if  the  child  is  taken  to  a  different  chmate.  The 
naso-pharynx  has  an  important  function  besides  being  a  passage-way  for 
the  air.  It  lubricates  the  pharynx,  and  by  the  action  of  its  muscles  opens 
the  Eustachian  tubes  during  the  acts  of  swallowing  and  yawning,  thus 
ventilating  the  ear.  The  prognosis,  therefore,  must  vary  according  to  the 
degree  in  which  any  of  these  functions  are  interfered  with.  When  infants, 
before  they  have  learned  to  articulate,  become  deaf  they  may  gradually 
lose  the  power  of  speech,  and  from  being  deaf  they  may  fall  into  a  con- 
dition of  hebetude  which  sometimes  closely  simulates  idiocy,  though  it  is 
not  true  idiocy,  for  the  mental  condition  quickly  changes  when  the  cause 
of  the  disturbance  has  been  removed.  Unless  irreparable  injury  has  been 
done  to  the  ear  or  to  the  general  development,  the  prognosis  is  very  favor- 
able, provided  the  proper  treatment  is  carried  out. 

Treatment. — The  best  treatment  of  these  cases  is  to  remove  the 
adenoid  growth  at  once.  The  operation  in  the  hands  of  a  skilful  surgeon 
is  not  dangerous,  and  should  be  unhesitatingly  advised.  There  are  a 
number  of  methods  which  have  been  employed  in  operating  on  these 
cases.  The  child  should  be  etherized,  or,  as  is  preferred  by  some  opera- 
tors, chloroform  may  be  employed.  Most  operators  prefer  to  have  the 
child  held  sitting  in  the  lap  of  an  attendant,  others  to  have  it  lying  down 
with  its  head  bent  backward.  Dr.  French,  of  Brooklyn,  uses  an  especial 
chair  adapted  by  him  for  operating  in  the  upright  position.  There  is  less 
liability  to  extreme  hemorrhage  and  to  infection  of  the  middle  ear 
through  the  Eustachian  tube  in  the  upright  position,  and  the  danger  of 
inspiring  the  blood,  which  has  been  given  as  a  reason  for  operating  in 
the  prone  position,  is  now  well  known  to  be  visionary.  The  instru- 
ment which  is  commonly  used  is  the  Gottstein  curette,  which  acts  on 
the  principle  of  a  draw-knife,  held  in  a  stirrup-shaped  frame ;  or  a  pair 
of  post-nasal  forceps  held  in  the  right  hand  is  introduced,  closed,  into  the 
naso-pharyngeal  cavity.  The  blades  are  then  opened,  and  pieces  of  the 
mass  are  grasped  one  after  the  other  and  pulled  off  gently  :  under  no 
circumstances  is  force  to  be  exerted.     With  proper  care  and  assistance 


648 


PEDIATRICS. 


there  is  no  danger  to  the  cliild,  and  often  in  a  few  minutes  a  morbid  con- 
dition which  has  existed  for  years  may  be  practically  cured.  There  are, 
of  course,  many  details  in  this  operation  which  must  be  thoroughly  un- 
derstood in  order  that  it  should  be  successful.  They  need,  however, 
scarcely  be  mentioned  here,  as  the  operation  should  be  performed  only 
by  one  whose  work  has  especially  fitted  him  for  it.  There  is  no  limit  to 
the  age  at  wliich  adenoids  may  be  removed.  As  soon  as  the  growth  has 
reached  such  proportions  as  to  cause  symptoms,  such  as  snuffles,  snoring, 
mouth  breathing  and  difficulty  in  nursing,  immediate  removal  is  indicated. 
This  may  be  done  as  early  as  six  or  eight  weeks  after  birth,  but  when 
removed  at  this  early  age  they  are  almost  certain  to  grow  again. 

These  growths  when  not  extensive  are  sometimes  removed  even 
without  ether  with  the  curette  or  the  finger-nail. 

The  follo^nng  case  illustrates  the  benefit  of  operative  treatment  for  the 
removal  of  the  pharyngeal  tonsil  when  hypertrophied. 

When  the  child  was  first  seen  at  two  years  of  age  he  had  a  very  bright  expression, 
and  spoke  well ;  he  showed  nothing  abnormal  in  connection  with  the  shape  of  his  nose 
or  face.  He  heard  well,  slept  with  his  mouth  shut,  and  had  a  free  passage  of  air  through 
a  perfectly  normal  nose  and  naso-pharynx.  When  he  was  three  and  a  half  years  old, 
however,  it  was  noticed  that  he  snored  at  night,  breathed  with  his  mouth  open,  and 
was  subject  to  continual  attacks  of  rliinitis  and  naso-pharyngeal  occlusion.  Following 
these  attacks  his  hearing  became  affected,  and,  while  in  his  second  year  he  had  been 
bright  and  always  ready  to  play  with  his  parents,  he  became  dull,  and  did  not  care  to 
play  with  others,  but  would  sit  for  hours  playing  by  himself  with  his  toys. 

A  digital  examination  showed  a  mass  of  considerable  size  blocking  the  posterior 
nares.  On  the  removal  of  this  mass,  which  proved  to  be  an  hypertrophied  pharyngeal 
tonsil,  rapid  improvement  took  place  in  his  general  condition,  the  dulness  and  hebe- 
tude disappeared,  and  he  returned  to  the  normal  condition  which  he  represented  in 
his  second  year. 

There  are  other  growths  which  occur  in  the  naso-pharynx,  such  as 
sarcomata.     They  are,  however,  too  rare  to  need  especial  description. 

DISEASES  OF  THE  PHARYNX. 

Diseases  of  the  pharynx  in  children  are  especially  those  affecting  the 
tonsils,  the  uvula,  the  soft  palate,  and  the  posterior  wall  of  the  pharynx. 

TONSILLrnS. 

By  tonsillitis  is  meant  an  inflammation  of  the  tissues  of  the  faucial 
tonsils.     This  inflammation  may  be  acute  or  chronic. 

Acute  Tonsillitis. — Acute  tonsillitis  (acute  follicular  tonsillitis,  acute 
cryptic  tonsillitis)  is  characterized  by  an  acute  swelling  and  redness  of  the 
glands,  and  an  exudation  from  the  crypts.  It  is  generally  bilateral,  but 
one  tonsil  may  be  affected  before  the  other.  The  disease  is  not  limited 
to  the  faucial  tonsils,  but  commonly  involves  neighboring  glandular  struc- 
tures, such  as  the  pharyngeal  and  lingual  tonsils. 


DISEASES    OF   THE   PHARYNX.  649 

Etiology. — The  cause  of  this  form  of  tonsilitis  is  undoubtedly  infec- 
tion by  some  pathogenic  germ.  It  is  probable  that  more  than  one  form 
of  germ  is  capable  (>f  causing  it.  Many  of  the  pathogenic  germs  which 
infest  the  mouth  or  the  throat  may  be  found  in  the  crypts  in  this  disease, 
but  the  especial. germ  by  which  we  can  characterize  the  disease  has  not 
yet  been  determined. 

Symptoms. — As  a  rule,  the  disease  is  characterized  by  acute  onset, 
with  a  heightened  temperature,  39.4°  to  40°C.  (103°  to  104°  F.),  loss 
of  appetite,  and  general  malaise.  We  have  often  noticed,  however,  that  the 
symptoms  of  a  marked  follicular  tonsillitis  are  not  so  acute  and  do  not  so 
definitely  point  to  the  throat  in  young  children  as  they  commonly  do  in 
older  children  and  in  adults.  In  fact,  in  many  cases,  unless  the  throat  is 
actually  inspected,  it  would  seem  as  though  the  symptoms  were  not  due 
to  a  local  affection  of  the  throat,  but  to  some  general  disease  affecting 
other  parts  of  the  system.  We  should  be  especiaUy  careful,  therefore, 
not  to  have  our  attention  diverted  from  the  throat,  but  under  all  cir- 
cumstances, where  these  symptoms  arise  in  young  children,  even 
though  they  apparently  swallow  without  discomfort,  the  throat  should 
be  examined  before  deciding  whether  or  not  some  other  disease  is  de- 
veloping. 

On  examining  the  throat  the  tonsils  are  seen  to  be  enlarged,  red- 
dened, and  in  the  early  hours  of  the  disease  to  show  a  little  swelling 
of  the  orifices  of  the  crypts,  as  though  a  secretion  within  them  was  about 
to  burst  the  overlying  mucous  membrane  and  appear  on  the  free  surface. 
Later  this  actually  occurs,  and  the  tonsils  are  seen  to  be  studded  with 
white  or  grayish-white  spots.  These  do  not  appear  on  the  soft  palate  or 
uvula,  though  they  may  appear  on  the  pharyngeal  tonsil,  the  base  of  the 
tongue,  and  the  posterior  pharyngeal  walls.  The  mucous  membrane  of 
the  pillars  of  the  palate,  of  the  uvula,  and  of  the  soft  palate  are  usually 
reddened,  and  there  is  very  apt  to  be  a  decided  reddening  and  even 
swellmg  of  the  mucous  membrane  and  follicles  of  the  pharynx.  As  the 
disease  progresses  these  spots  may  coalesce  and,  adhering  to  the  surface 
of  the  tonsil,  form  a  pseudo-membrane  which  is  often  impossible,  without 
a  bacteriological  examination,  to  distinguish  from  diphtheria.  As  there 
is  a  direct  connection  between  the  tonsils  and  the  cervical  glands,  the  latter 
are  liable  to  be  involved,  though  any  great  swelling  of  the  cervical  glands 
in  connection  with  acute  tonsillitis  is  uncommon. 

The  disease  is  self-limited,  and  runs  its  course  in  two  or  three  days  or 
a  week,  at  the  end  of  which  time  the  general  symptoms  subside,  the 
appetite  returns,  the  temperature  becomes  normal,  and  the  child,  although 
it  is  left  somewhat  weakened  by  the  disease,  seems  as  well  as  ever.  The 
tonsils  themselves,  however,  may  not  for  some  time  regain  their  original 
sile,  and  the  exudation  often  remains  in  the  crypts  and  may  cause  a 
chronic  irritation  with  a  tendency  to  recurrence. 

Diagnosis. — The  differential  diagnosis  of  follicular  tonsillitis  is  to  be 


650  PEDIATRICS. 

made  from  the  various  forms  of  stomatitis,  which  have  already  been 
sufficiently  described,  and  from  diphtheria.  It  is  now  very  generally 
known  that  it  is  impossible  absolutely  to  exclude  diphtheria  by  the  morbid 
appearances  seen  on  the  tonsils.  In  the  great  majority  of  instances,  how- 
ever, when  the  attack  is  acute,  when  the  cervical  glands  are  not  especially 
involved,  when  the  white  spots  on  the  tonsils  are  clearly  located  in  the 
orifices  of  the  crypts,  and  when  there  is  no  appearance  of  a  membrane 
on  the  soft  palate  or  pharyngeal  wall,  we  can  make  a  provisional  clinical 
diagnosis  of  follicular  tonsillitis  with  considerable  confidence,  but  never 
with  certainty  without  a  bacteriological  examination. 

Prognosis. — The  prognosis  of  follicular  tonsillitis  is  in  almost  every 
case  favarable,  and  is  rendered  unfavorable  only  by  the  complication  of 
a  peritonsillar  abscess,  but  it  should  be  remembered  that  in  an  inflamed 
tonsil  pathogenic  organisms,  such  as  those  of  diphtheria,  are  more  apt  to 
develop  than  when  there  is  no  inflammation. 

Treatment. — The  treatment  of  acute  tonsillitis,  according  to  our  ex- 
perience, should  be  entirely  symptomatic.  It  is  a  self-limited  disease,  and 
in  a  vast  majority  of  cases  is  not  shortened  by  the  administration  of  any 
drug  internally  or  by  local  applications.  In  order  to  avoid  the  invasion  of 
the  various  pathogenic  germs  during  the  progress  of  the  tonsillitis  we 
are  in  the  habit  of  having  the  throat  kept  thoroughly  clean  with  mild 
solutions  of  chlorate  of  potassium  or  borate  of  sodium.  In  young  chil- 
dren, as  a  rule,  we  make  no  local  application  beyond  allowing  them  to 
swallow  cold  solutions  of  chlorate  of  potassium  in  the  strength  which  we 
have  advised  in  Table  66,  page  622.  Small  doses  of  quinine,  salol,  and 
phenacetine  combined,  or  antipyrin  and  sodium  bromide,  according  to  the 
age  of  the  child,  are  indicated  Avhen  there  is  much  exhaustion  or  malaise 
following  the  attack.  As  many  cases  of  tonsillitis  are  rheumatic  in  origin, 
aspirin  alone  or  in  combination  with  small  doses  of  Dover's  powders  are 
often  of  benefit. 

The  local  application  of  a  cleansing  spray,  and  the  administration  of 
_ice  if  desired  to  relieve  the  discomfort,  constitute  all  that  is  necessary  for 
the  treatment  of  most  cases.  It  is  best  not  to  disturb  the  mucous  mem- 
brane with  applications  on  swabs  or  brushes. 

The  following  case  represents  a  follicular  tonsillitis : 

A  child  (Plate  XII.,  facing  page  618,  Follicular  Tonsillitis),  four  years  old,  had  an 
attack  of  follicular  tonsillitis. 

She  was  taken  sick  two  days  before  entering  the  hospital,  with  a  heightened  tem- 
perature of  about  39.4°  C.  (103°  F.),  loss  of  appetite,  and  general  malaise.  She  did 
not  complain  of  her  throat,  and  swallowed  without  difficulty.  Nothing  abnormal  was 
found  in  any  of  the  other  organs,  but  on  inspecting  the  throat  the  tonsils  were  seen  to 
be  enlarged  and  much  reddened,  and  one  or  two  of  the  orifices  of  the  crypts  were 
somewhat  raised  above  the  general  surface  of  the  tonsil.  •  On  the  following  day  a 
number  of  white  spots  of  different  sizes  appeared  on  both  tonsils.  On  the  day 
of  entrance  the  redness  was  mostly  confined  to  the  tonsils,  and  afi"ected  the  uvula  and 
palate  A^ery  little.     On  the  inner  surface  of  both  tonsils  the  exudation  had  coalesced, 


DISEASES   OF   THE   PHARYNX.  651 

so  that  it  had  an  appearance  very  much  like  that  of  a  pseudo-membrane.  It  is  not 
uncommon  in  folhcular  tonsillitis  for  this  coalescence  of  the  exudation  to  take 
place  on  the  surface  of  the  tonsil  which  points  towards  the  median  line  of  the  throat. 
The  other  appearances  of  the  tonsils  were  characteristic  of  follicular  tonsillitis.  On 
the  upper  left-hand  corner  of  tlie  left  tonsil,  close  to  the  arch  of  the  palate,  was  an 
enlarged  cryptic  orifice  which  had  not  quite  broken  down,  and  which  appeared  as  a 
light  red  prominence  on  the  general  surface  of  the  tonsils.  The  orifices  had  a  like 
appearance  in  various  parts  of  both  tonsils.  On  the  anterior  surface  of  the  left  tonsil 
were  two  white  spots,  caused  by  the  exudation  from  the  crypts.  In  the  upper  part  of 
the  right  tonsil  were  three  smaller  yellowish-white  spots,  and  lower  down  on  the 
tonsil  a  grayish-white  rather  large  spot,  all  of  them  due  to  the  same  cause.  There 
were  no  other  lesions  in  the  throat,  and  the  cervical  glands  were  not  involved. 

Cultures  made  from  this  exudation  did  not  show  the  presence  of  the  Klebs- 
Loeffler  bacillus. 

The  other  affections  of  the  tonsils,  such  as  occur  in  the  course  of  the 
exanthemata  and  in  diphtheria,  constituting  the  pseudo-membranous 
form  of  the  disease,  can  best  be  described  in  connection  with  tlie  especial 
diseases  in  which  they  arise. 

Chronic  Tonsillitis. — The  terms  chronic  tonsillitis  and  hypertropliied 
or  enlarged  tonsils  are  commonly  used  to  express  the  same  condition, 
especially  in  children,  in  whom  a  chronic  inflannnation  of  the  tonsils  un- 
accompanied by  enlargement  seldom  occurs. 

Although  this  hypertrophy  of  the  faucial  tonsils  may  exist  without  a 
corresponding  affection  of  the  pharyngeal  tonsil,  yet  it  is  very  apt  to  be 
associated  with  this  latter  condition. 

Pathological  Anatomy. — The  enlargement  is  a  true  hypertrophy, 
sometimes  accompanied  by  more  or  less  inflammatory  deposit.  If  the 
parenchymatous  or  glandular  tissues  are  especially  affected  we  find  a  soft, 
more  or  less  red  and  vascular  tonsil,  with  large  crypts,  often  containing 
much  secretion.  In  the  interstitial  form  the  tonsil  is  hard  and  tough,  the 
crypts  less  prominent  or  even  very  small,  and  the  vascularity  much 
diminished.  These  types  are  the  two  extremes,  and  are  rare ;  in  most 
cases  the  enlargement  is  essentially  one  of  hypertrophy.  The  tonsils 
may  be  only  moderately  enlarged,  or  their  size  may  be  so  increased  that 
they  meet,  touching  each  other  in  the  median  line. 

Symptoms. — The  symptoms  of  hypertrophy  of  the  faucial  tonsils  vary 
according  to  the  degree  of  enlargement.  Normally  the  tonsils  can 
scarcely  be  seen  on  inspection  of  the  throat.  In  examining  a  child  for 
enlargement  of  the  tonsils  care  must  be  taken  that  the  pharynx  is  not 
contracted  by  gagging  at  the  time  the  examination  is  made.  The  act  of 
gagging,  which  is  easily  brought  about  in  children  by  a  careless  use  of  the 
tongue-depressor,  brings  the  tonsils  towards  the  median  line,  thus  giving 
tonsils  of  normal  size  the  appearance  of  being  large  and  obstructive. 
When  only  moderately  enlarged  they  may  produce  no  symptoms  what- 
ever, or  they  may  be  irritated  by  various  external  influences  and  be  the 
source  of  recurrent  acute  affections  of  the  throat.     When  considerably 


g52  PEDIATRICS. 

enlarged  they  may  still  not  produce  any  marked  symptoms,  provided  tliat 
the  passage  of  air  through  the  naso-pharynx  is  unobstructed.  They  may, 
however,  even  when  the  pharyngeal  tonsil  is  not  enlarged,  cause  ob- 
struction in  the  naso-pharynx  by  pressure  as  they  enlarge  upward  and 
backward.  When  this  happens,  the  same  interference  with  the  breathmg 
and  development  of  the  child  takes  place  as  when  the  obstruction  is 
primarily  in  the  naso-pharynx.  These  symptoms  are  the  same  as  have 
already  been  described  in  speaking  of  hypertrophy  of  the  pharyngeal 
tonsil,  and  therefore  need  not  be  mentioned  in  detail  here. 

Occasionally  difficulty  in  swallowing  and  thickness  of  speech  may 
arise  when  only  the  faucial  tonsils  are  enlarged. 

Prognosis, — The  prognosis  in  cases  of  hypertrophy  of  the  faucial 
tonsils  depends  upon  these  varied  anatomical  conditions  just  described. 
So  long  as  the  tonsils  do  not  encroach  on  the  naso-pharynx  the  prog- 
nosis, so  far  as  injury  to  the  child  is  concerned,  is  good.  We  should 
remember,  however,  that  the  enlargement  of  the  tonsils  is  a  fertile  source 
of  irritation  Avhich  may  prepare  the  way  for  serious  disease  produced  by 
the  various  micro-organisms.  The  prognosis  as  to  their  disapi^earance  is 
not  especially  good,  as  when  once  hypertrophied  they  seldom  recover 
their  normal  size  without  active  treatment,  though  they  generally  diminish 
slowly  in  size  after  puberty. 

Treatment. — Local  applications  for  the  reduction  of  hypertrophied 
tonsils  are  useless.  Some  success  has  been  obtained  by  Gampert  by  what 
is  called  discission  of  the  tonsils.  Leland  has  strongly  advocated  this 
treatment  in  certain  cases.  The  operation  consists  in  making  slits  in  the 
tonsil  with  a  knife  especially  devised  by  him. 

The  most  thorough  and  certain  way  of  curing  the  disease  is,  however, 
by  excision.  If  the  pharyngeal  tonsil  also  is  hypertrophied  the  child 
should  have  an  anaesthetic,  and  the  operation  for  adenoid  vegetations  and 
tonsils  should  be  done  at  the  same  tune.  If  the  tonsils  alone  are  en- 
larged, they  may  be  excised  with  the  tonsillotome  without  an  auEesthetic, 
provided  they  are  not  adherent  to  the  pillars  of  the  fauces.  After  the 
operation  the  child  should  be  made  to  gargle  with  a  solution  of  borate  of 
sodium  for  two  or  three  days  (Prescription  45),  and  should  be  given  only 
milk  for  its  food. 

Pbescriptiox   45. 
Metric.  Apothecary. 

Gramma. 

B   Sodii  Borat 2iO         R    Sodii  Borat gr.  xxx ; 

Glycerinse 20|0  GlyceriiiEe g  v  ; 

Aq.  destil 18o[o  Aq.  destil |  vi. 

M.  M. 

Sig. — Gargle  for  throat. 

The  hypertrophied  tonsils  may  have  become  adherent  to  the  anterior 
or  the  posterior  pillars  of  the  fauces  to  such  an  extent  that  the  guillotine 
either  cannot  be  used,  or  not  without  danger  of  wounding  these  pillars. 


DISEASES    OF    THE    PHARYXX. 


653 


In  such  cases  it  may  be  necessary  to  resort  to  dissection  or  to  the  gal- 
'vano-cautery  to  remove  the  tonshlar  tissue. 

PEKETONSILLAil    ABSCESS. 

Symptoms. — In  some  cases  an  inflammatory  process  resulting  in  sup- 
puration occurs  in  the  cellular  tissue  around,  above,  or  behind  the  tonsil, 
constituting  an  abscess  which  is  called  peritonsillar.  It  is  rather  rare  in 
early  childhood.  The  disease  is  usually  preceded  by  a  certain  degree  of 
simple  tonsillitis,  and  when  it  develops  the  temperature  rises,  perhaps  to 
40°  or  40.5°  C.  (104°  or  105°  F.),  and  the  child  evidently  suffers  much 
pain,  and  has  difficulty  in  swallowing  or  even  in  opening  the  mouth. 

On  inspecting  the  throat  in  these  cases  a  unilateral  swellmg  is  seen  in 
the  neighborhood  of  the  tonsil  pushing  the  soft  palate  forward,  and  the 
tonsil  towards  the  median  line. 

Prognosis. — The  prognosis  is  in  almost  every  case  favorable,  except 
in  those  which  have  been  neglected  or  improperly  treated.  There  is 
rarely  extensive  burrowing  of  the  pus. 

Treatment. — The  treatment  is  to  locate  the  abscess  by  careful  pal- 
pation and  to  open  it  under  strict  antiseptic  precautions  with  a  guarded 
bistouiy. 

PHARYNGITIS. 

An  inflammatory  condition  of  the  posterior  wall  of  the  pharynx  is 
rather  rare  in  infancy,  but  is  not  uncommon  in  children.  It  is  usually 
coincident  with  an  inflammatory  condition  of  the  naso-pharjmx  or 
of  the  tonsils,  but  in  a  certain  number  of  cases  it  is  so  much  more 
pronounced  in  the  posterior  wall  than  elsewhere  that  it  can  be  de- 
scribed as  a  separate  disease.  The  diseases  of  the  posterior  wall  of 
the  phanmx  are  either  (1)  a  simple  catarrhal  condition  of  the  mucous 
membrane  or  (2)  an  inflammatory  process  in  which  the  follicles  are 
especially  affected.  In  addition  to  these  conditions,  pus  may  form  be- 
hind the  mucous  membrane,  producing  a  retropharyngeal  abscess.  The 
inflammatory^  lesions  of  the  pharynx  may  be  acute  or  chronic. 

The  conditions  which  give  rise  to  pharyngitis  are  the  same  various 
morbid  processes  that  involve  the  parts  in  the  neigliborhood  of  the 
phan-nx.  such  as  the  naso-pharynx  and  the  tonsils.  These  causes  have 
already  been  mentioned.  There  also  seems  to  be  a  connection  between 
certain  irritations  arising  in  the  gastro-enteric  tract  and  the  pharynx. 
When  this  occurs  it  is  usually  the  chronic  form  of  pharjTigitis  which  is 
met  with,  and  the  causal  connection  between  these  two  distant  parts  of 
the  economy  is  probably  of  a  reflex  nature. 

Acute  Simple  Pharyngitis. — The  pathological  condition  which  is 
found  in  the  simple  acute  form  of  phan'ngitis  is  an  acute  inflammation 
characterized  by  a  slightly  heightened  temperature,  a  hj-pertemic  con- 
dition of  the  blood-vessels  of  the  posterior  wall  of  the  pharynx,  and  a 
certain  amount  of  swelling  and  of  serous  exudation. 


654  PEDIATRICS. 

SymptOxMS, — The  symptoms  are  discomfort  in  swallowing,  and  at  first 
a  feeling  of  dryness  in  the  throat,  followed  later  by  an  exudation  of  viscid 
mucus.  The  child  does  not  seem  especially  sick  with  this  disease,  and 
the  lengih  of  the  attack  varies  according  to  the  influences  which  are 
causing  it. 

.  Acute  Follicular  Pharyngitis. — Symptoms. — The  acute  follicular  form 
of  pharj'ngitis  does  not  differ  materially  in  its  symptoms  from  the  simple 
form,  and  in  fact  both  forms  are  so  frequently  combined  that  a  clinical 
distinction  need  scarcely  be  made  between  them.  On  examming  the 
pharynx  in  this  form  of  pharyngitis,  in  addition  to  the  appearances  which 
are  seen  in  the  simple  form,  the  follicles  will  be  found  enlarged  and 
raised  above  the  surface  of  the  mucous  membrane. 

Treatment. — The  treatment  of  both  forms  of  pharj^ngitis  is  essentially 
local,  and  is,  as  a  rule,  by  applications  to  the  inflamed  mucous  membrane 
in  the  form  of  a  spray,  either  directly  or  indirectly  through  the  nose. 
The  spray  is  essentially  for  the  purpose  of  cleansing  and  thus  soothing 
the  inflamed  mucous  membrane,  and  should  consist  of  mild  alkaline 
solutions  such  as  the  following : 

Prescription   46. 
Metric.  Apothecary. 

Gramma. 

B   Sodii  cliloridi Oj3         R   Sodii  chloridi gr.  v 

Sodii  "bicarb.,  Sodii  bicarb., 

Sodii  boratis aa     Oj9  Sodii  boratis aa  gr.  xv  ; 

Aquie  rosse 30:0  Aquse  rosaj ^  i ; 

Aquffi 90|0  Aquie g  iii. 

M.  M. 

Sig. — Spray  for  pharyngitis. 

Chronic  Pharyngitis. — The  chronic  fomi  of  pharyngitis  is  usually 
accompanied  by  an  irritating  cough,  which  is  most  pronounced  at  night 
and  in  the  morning.  The  mistake  should  not  be  made  of  thinking  that 
these  children  who  are  coughing  continuously,  often  losing  in  weight  and 
looking  weak  and  ansemic,  are  necessarily  affected  with  bronchitis.  This 
series  of  symptoms  is  frequently  looked  upon  as  diagnostic  of  bronchitis, 
when  it  really  arises  from  pharyngitis,  and  can  be  cured  by  treating  the 
latter  cUsease. 

Treatment. — The  treatment  of  chronic  pharyngitis  is  to  remove  any 
hypertrophic  condition  of  the  tonsils,  tongue,  or  nose,  to  regulate  care- 
fully the  child's  general  nutrition,  and  to  avoid  undue  exposure  to  in- 
clement weather  or  to  air  vitiated  in  any  way.  as  by  dust.  Local  applica- 
tions of  a  one  per  cent,  solution  of  nitrate  of  silver,  followed  immediately 
by  thorough  cleansing  with  sterilized  water,  are  sometimes  indicated  in 
the  more  intractable  cases, 

Blong-ation  of  the  Uvula. — Symptoms. — Accompanying  pharjmgitis, 
usually  in  its  chronic  form,  an  elongation  of  the  uvula  is  at  times  met 
with  in  children.     This  condition  may  arise  from  a  relaxed  condition  of 


DISEASES   OF   THE   PHARYNX.  655 

the  muscles  of  the  soft  palate  and  of  the  uvula,  or  may  consist  simply  of 
a  redundancy  of  the  mucous  membrane  at  the  tip  of  the  uvula.  The 
general  irritated  condition  of  the  uvula  and  the  tickling  sensation  pro- 
duced by  its  elongated  tip  toucliing  the  base  of  the  tongue  cause  a  harass- 
ing cough,  which  by  its  persistence  weakens  the  cliild,  gives  rise  to  loss 
of  appetite,  and  interferes  with  its  nutrition. 

A  papillomatous  growth  is  sometimes  found  attached  to  the  tip  of  the 
uvula  or  to  its  side,  which  causes  the  same  symptoms  as  elongation  of 
the  uvula.     The  treatment  is  excision,  after  which  it  does  not  recur. 

Treatment. — Local  applications  of  astringents,  such  as  alum,  are  at 
times  sufficient  to  restore  the  uvula  to  its  normal  condition,  but  the  dis- 
ease can  be  cured  cjuickly  by  excising  the  end  of  the  uvula  with  blunt- 
pointed  scissors.  The  amputation  of  the  entire  uvula  is  to  be  avoided, 
as  it  has  been  known  to  weaken  the  muscular  action  of  the  soft  palate. 

RETROPHARYNGEAL    ABSCESS. 

Retropharyngeal  abscess  is  a  cUsease  which  occurs  usually  during  the 
first  year  of  life  and  is  yerj  rare  after  this  time.  The  disease  may  be 
secondarj^  to  injuries  of  the  pharynx,  to  abscess  in  the  neck,  and  to  dis- 
ease of  the  cenical  vertebrae,  or  it  may  be  metastatic  from  septic  pro- 
cesses such  as  occur  in  chphtheria.  In  a  certain  number  of  cases  it  is 
idiopatliic  so  far  as  we  know. 

Pathological  Axatomt. — The  pathology  of  the  disease  consists  in  the 
formation  of  an  abscess  in  the  tissues  of  the  posterior  wall  of  the  pharynx, 
which  is  more  apt  to  be  on  one  side  of  the  pharynx  than  in  the  median  line. 

Symptoms. — The  symptoms,  whether  the  disease  is  primary  or  second- 
ary, are  very  much  the  same.  The  first  symptom  is  generally  difficulty 
in  swallowing,  which  may  go  on  to  entire  inability  to  swallow.  The  infant 
is  next  noticed  to  breathe  in  a  peculiar  way.  It  holds  its  head  back  and 
its  mouth  open.  The  breathing  may  be  described  as  snorting,  and  at 
times  as  almost  stertorous,  diff'ering  markedly  from  the  whistling  sound 
which  is  heard  in  obstruction  of  the  larynx.  On  examining  the  throat 
the  soft  palate  is  seen  to  be  pushed  forward  and  to  be  somewhat  angemic. 
The  posterior  wall  of  the  pharynx  is  bulging,  usually  unilaterally,  is 
reddened,  swollen,  tense,  and  as  the  disease  progresses  is  found  to  be 
fluctuating.  In  some  cases  the  abscess  burrows  into  the  tissues  of  the 
neck  and  appears  as  a  pear-shaped  tumor  behind  the  ear.  We  have  met 
with  several  cases  of  this  variety  where  the  pus  could  be  reached  easily  by 
an  external  incision. 

Diagnosis. — The  diagnosis  must  be  made  chiefly  from  peritonsillar 
abscess.  This  is,  as  a  rule,  not  difficult  unless  the  latter  condition  has 
proceeded  so  far  that  the  pus  by  burrowing  has  invaded  the  walls  of  the 
pharjmx.  It  is  usually  not  difficult  to  determine  the  situation  of  the 
abscess  by  passing  the  finger  directly  through  the  mouth  to  the  posterior 
wall    of  the   pharynx.     If  there  is  pus  in  the  tissues  of  the  pharynx  a 


656 


PEDIATRICS. 


sense  of  fluctuation  will  be  obtained.  The  position  of  the  child  in  cases 
of  retropharyngeal  abscess  is  also  significant,  and  is  not  that  which  is 
assumed  in  peritonsillar  abscess.  It  holds  its  head  back,  in  order  to  allow 
a  free  passage  for  the  air  through  the  occluded  pharynx  into  the  larynx. 

The  diagnosis  must  also  be  made  from  oedema  of  the  glottis,  but  this 
is  not,  as  a  rule,  difficult,  for  inspection  shows  that  in  the  latter  disease, 
bulging,  redness,  swelling,  and  fluctuation  of  the  posterior  wall  of  the 
pharynx  are  not  present.  The  characteristic  position  of  the  head,  also, 
is  not  seen  in  oedema  of  the  larynx.  A  case  of  retropharyngeal  abscess 
can  often  be  diagnosticated  by  the  snorting  and  labored  character  of  the 
respiration. 

Prognosis. — The  prognosis  in  the  cases  in  which  the  abscess  is  second- 
ary varies  according  to  the  nature  of  the  disease  which  causes  it.  Thus, 
it  is  an  exceedingly  dangerous  complication  in  diphtheria,  and  is  one  of 
serious  import  in  cervical  spondylitis.  In  those  cases  of  undetermined 
origm  which  are  spoken  of  as  idiopathic  the  prognosis  is  very  good  if  the 
proper  treatment  is  carried  out  at  once.  We  must,  however,  consider  the 
possibility  of  the  abscess  bursting  suddenly  and  of  the  child  suffocating  by 
inspiration  of  pus  into  the  larynx.  This  has  been  known  to  occur  when 
the  disease  has  been  left  untreated. 

Treatment. — In  the  idiopathic  cases  the  abscess  should  be  opened  at 
once.  The  method  which  we  have  found  satisfactory  in  the  cases  which 
have  come  under  our  observation  is  to  have  an  assistant  hold  tlio  infant 
sitting  upright  in  the  lap,  with  a  blanket  tightly  pinned  around  it  so  as  to 
prevent  it  from  moving  its  arms.  Another  assistant  should  hold  the  head. 
The  mouth  should  then  be  opened,  a  guarded  bistoury  should  be  intro- 
duced into  the  pharynx  and  the  abscess  punctured.  As  soon  as  the  open- 
ing has  been  made  the  bistoury  should  be  removed  quickly,  and  the 
infant's  head  should  be  immediately  thrown  forward  and  downward,  so 
that  the  pus  will  be  discharged  from  its  mouth  and  not  inspired  into  the 
larj^nx  or  swallowed.  It  is  usually  necessary  after  the  operation  to  intro- 
duce the  fmger  into  the  pharynx  and  to  press  the  walls  of  the  abscess,  so 
as  to  empty  any  pus  which  may  continue  to  collect  there  and  also  to  keep 
the  opening  free.  With  this  treatment,  unless  some  complication  should 
arise,  the  disease  is  usually  cured  in  about  a  week. 

Some  operators  prefer  having  the  child  placed  in  what  is  known  as 
Rose's  position,  on  its  back  with  the  head  hanging  over  the  end  of  the 
table. 

Fig.  140  represents  a  typical  case  of  retropliaryngeal  abscess  in  an  infant  seven 
months  old,  sliowing  the  characteristic  appearance  produced  by  the  obstruction  in  tlie 
pharynx.  The  head  was  held  back  and  the  mouth  open  ;  the  eyes  were  somewhat 
rolled  upward,  but  she  was  perfectly  conscious.  The  face  was  slightly  cyanotic.  On 
depressing  the  lower  jaw  and  tongue  the  soft  palate  was  seen  pressed  forward,  and  the 
blood-vessels  were  found  to  be  almost  empty  and  very  pale.  On  the  left  of  the  median 
line  a  swollen,  congested,  bulging  condition  of  the  mucous  membrane  was  seen  on 


DISEASES   OF   THE   PHARYNX.  657 

throwing  a  strong  light  from  the  mirror  on  tlie  posterior  wall  of  the  pharynx.  On 
touching  the  most  prominent  point  of  the  swelling  with  the  finger  a  sense  of  fluctuation 
was  obtained. 

The  infant  was  said  to  have  been  sick  for  two  weeks  with  a  cold  in  its  head.  Three 
days  before  we  saw  it  it  began  to  Ijreathe  in  a  labored  manner  and  to  hold  its  head  back 
rigidly  and  somewhat  to  the  left.  It  also  began  to  hold  its  mouth  open.  It  was  able  to 
nurse  only  a  few  seconds  at  a  time,  when  it  would  let  go  of  the  nipple  and  refuse  to 
take  it  again.  It  had  been  growing  very  weak  from  lack  of  nourishment  and  from  the 
exhaustion  arising  from  the  difficulty  in  breathing. 

Pig.  ho. 


Retropharyngeal  abscess.    Male,  7  months  old. 


An  opening  in  the  abscess  was  made,  and  a  large  amount  of  pus  was  evacuated. 
An  hour  later  the  child  began  to  choke,  and  it  seemed  as  though  tracheotomy  would 
have  to  be  performed,  but  pressure  with  the  finger  on  the  walls  of  the  abscess  from 
time  to  time,  surrounding  the  infant  with  an  atmosphere  containing  steam,  and  free 
stimulation,  proved  eventually  to  be  all  that  was  necessary  for  its  recovery. 

The  next  case  was  one  of  an  infant  thirteen  months  old,  always  strong  and 
healthy,  who  had  an  attack  of  acute  rhinitis  for  several  days.  The  rhinitis  apparently 
caused  considerable  swelling  and  occlusion  of  the  nares,  and  the  infant  after  four  or  five 
days  began  to  hold  its  mouth  open  when  breathing  and  to  have  difficulty  in  swallow- 
ing. This  difficulty  in  deglutition  increased,  and  it  was  then  noticed  that  her  head 
was  held  back.  On  examining  the  throat  a  tense  fluctuating  swelling  was  detected  in 
the  posterior  wall  of  the  pharynx  very  nearly  in  the  median  line.  This  swelling  was 
incised,  a  considerable  amount  of  pus  was  evacuated,  and  the  infant  immediately  began 
to  breathe  more  easily  and  was  able  to  swallow  without  difficulty.  During  the  next 
twenty-four  hours  the  abscess  filled  with  pus  a  number  of  times,  and  the  pus  had  to 
be  emptied  by  pressure  with  the  finger.  The  infant  made  a  perfect  recovery,  and  had 
no  return  of  the  disease. 

In  an  ordinary  case,  when  the  pus  has  come  from  the  breaking  down 
of  glandular  material  in  the  posterior  wall  of  the  pharynx  and  already 
contains  pyogenic  bacteria,  the  dangers  from  reinfection  from  a  wound  in 
the  mouth  are  not  serious.  But  when  the  pus  has  come  from  a  tubercular 
focus  in  the  cervical  vertebrae  and  contains  no  other  organisms  than  the 
tubercle  bacillus,  and  is,  moreover,  in  direct  communication  with  an  active 
pathological  process  in  the  bone,  the  risks  of  a  secondary  septic  infec- 
tion are  considerable.  It  is,  therefore,  the  practice  of  many  surgeons, 
nothwithstanding  the  difficulties  of  the  operation,  to  attempt  to  reach  the 
abscess  by  a  careful  dissection  from  the  outside  of  the  neck,  as  in  this  way 

42 


(358  PEDIATRICS. 

it  is  far  easier  to  keep  the  wound  aseptic.    If  there  is  any  sign  of  the  abscess 
pointing  externally,  the  external  operation  should  always  be  preferred. 

In  the  following  case  the  retropharyngeal  abscess  was  secondary  to 
cervical  spondylitis. 


Retropharyngeal  abscess  secondary  to  cervical  spondylitis. 

This  child  was  being  treated  for  cervical  spondylitis,  when  in  addition  to  the  drawing 
back  of  its  head,  as  shown  in  Fig.  141,  it  began  to  have  increased  difficulty  in  swal- 
lowing and  to  breathe  with  its  mouth  open. 

On  examining  the  pharynx  a  bulging,  tense,  fluctuating  abscess  of  moderate  size 
was  detected. 


DIVISION    X. 

DISEASES  OF  THE  LARYNX,  TRACHEA,  BRONCHI, 
LUNGS,  AND  PLEURA. 


DISEASES  OF  THE  LARYNX. 

The  affections  of  the  larynx  which  occur  most  commonly  in  infants 
and  in  young  children  are  neuroses,  new  growths,  lesions  produced  by 
foreign  bodies,  oedema,  and  laryngitis. 

T  ■  A  RYNGOSPASMUS. 

Laryngospasmus  (laryngismus  stridulus)  is  a  neurosis  which  especially 
affects  the  larynx  in  infancy  and  childhood,  and  will  be  described  under 
the  name  of  laryngospasmus  when  speaking  of  reflex  irritation  of  the 
larynx  on  page  966. 

There  is  a  form  of  laryngospasmus  known  as  congenital  stridor,  char- 
acterized by  a  croaking  sound  accompanying  inspiration,  sometimes  by  a 
crowing  sound.  There  is  no  dyspnoea,  cyanosis,  or  diminution  in  the 
power  of  the  child  to  cry  or  to  cough.  Expiration  is  usually  noiseless.- 
The  stridor  is  apt  to  increase  in  loudness  during  the  first  few  months  of 
life,  but  gradually  disappears  during  the  second  year.  Thomson  and 
Turner  have  concluded  from  a  careful  anatomical  study  that  the  sound  is 
due  to  a  valvular  action  of  the  upper  aperture  of  the  larynx  by  which  its 
lateral  walls  are  drawn  inward  during  inspiration.  This  is  due,  not  to  a 
congenital  malformation,  but  to  an  incoordination  and  to  spasmodic  action 
of  the  muscles  of  respiration,  which  they  call  a  choreiform,  respiratory 
spasm,  analagous  to  stammering,  and  differing  from  a  laryngeal  spasm. 

NE'W  GRO"WTHS. 
New  growths  in  the  larynx  in  infants  and  in  children  are  rare.  They 
may  be  congenital,  but  these  are  very  uncommon.  They  may  be  malig- 
nant, such  as  epitheliomata  and  sarcomata,  or  benign,  such  as  fibromata, 
myxomata,  and  papillomata.  Those  of  the  former  class  are  so  rare  that 
they  need  here  only  be  referred  to.  Of  the  latter  class  the  fibromata  and 
myxomata  are  too  rare  to  be  more  than  mentioned.  The  papillomata, 
on  the  other  hand,  although  rare,  are  the  most  common  laryngeal  growths 
in  early  life.     They  may  produce  such  serious  results  that  it  is  important 

659 


660  PEDIATRICS. 

to  recognize  them  at  once.     They  may  be  congenital.     Their  cause  is  not 
known.     Papilloma  of  the  larynx  in  yomig  children  is  usually  multiple. 

The  symptoms  of  this  growth  appear  at  about  the  first,  second,  or 
third  year.  The  first  symptom  that  is  noticed  is  hoarseness.  This  hoarse- 
ness, instead  of  passing  off  in  a  few  days,  as  is  common  when  it  arises 
from  other  affections  of  the  larynx,  continues  and  grows  more  marked. 
The  next  symptom  is  dyspnoea.  This  appears  at  intervals  of  a  few 
months,  or  may  not  arise  for  some  years  after  the  first  alteration  of  the 
voice.  The  dyspnoea  first  appears  at  night,  wheji  the  child  is  asleep. 
In  the  daytime,  when  the  child  is  awake  and  running  about,  it  may 
breathe  freely.  As  the  papillomata  increase  in  size,  the  dyspnoea  appears 
in  the  daytime  also,  especially  when  the  child  makes  any  exertion.  When 
it  is  awake  and  is  quiet  the  breathing  may  not  be  noticeably  affected, 
even  after  the  growth  has  attained  a  large  size.  Cough  may  be  present. 
Usually  there  is  no  pain  nor  difficulty  in  swallowing.  When  a  child  pre- 
sents these  symptoms  a  careful  laryngoscopic  examination  should  be 
made  at  once,  as  in  this  way  only  can  the  diagnosis  be  verified. 

Prognosis. — The  prognosis  in  these  cases  is  bad  unless  the  growths 
are  removed. 

Treatment. — The  best  treatment  of  multiple  papillomata  is  to  remove 
the  growths  through  the  mouth.  This  is,  however,  a  difficult  operation. 
Without  an  anaesthetic  it  is  hard  to  control  the  child,  and  many  attempts 
may  be  required.  With  an  aneesthetic,  if  the  growth  is  sufficient  to  cause 
much  obstruction  there  may  be  cessation  of  breathing  during  the  opera- 
tion, requiring  immediate  tracheotomy.  Many  operators  prefer  to  do  a 
previous  tracheotomy,  especially  as  it  may  require  more  than  one  opera- 
tion to  clear  the  larynx.  Intubation  has  been  recommended,  but  it  is 
attended  with  the  danger  of  breaking  off  some  of  the  growth  which  may 
find  its  way  into  a  bronchus. 

The  difficulty  of  removal  is  in  some  cases  so  great  that  some  of  the 
most  competent  operators  have  preferred,  if  the  case  is  not  urgent,  to 
postpone  the  operation  until  the  child  is  older.  The  child  during  this 
time  must  be  kept  under  strict  supervision,  but  local  applications  are  not 
indicated.  These  growths,  even  when  completely  removed,  have  a  ten- 
dency to  recur. 

FOREIGN  BODIES. 

Foreign  bodies  rarely  lodge  in  the  larynx,  but  this  accident  occurs 
more  commonly  in  children  than  in  adults,  as  children  are  apt  to  put 
articles  of  every  description  into  their  mouths. 

The  symptoms  which  indicate  the  presence  of  a  foreign  body  in  the 
larynx  are  a  sudden  attack  of  suffocation  and  a  change  in  the  sound  of  the 
voice  in  a  child  who  has  previously  shown  no  signs  of  obstruction  and  no 
symptoms  of  laryngeal  disease. 

The  accident  is  one  which  is  so  serious  that  the  child  should  be  placed 
at  once  in  the  hands  of  a  laryngologist.     The  larynx  should  be  examined 


DISEASES    OF   THE  LARYNX.  661 

with  the  laryngoscope,  and  the  foreign  body  removed,  if  possible,  ^\ath  the 
forceps.  Great  care  should  be  taken  not  to  push  the  foreign  body  into 
the  trachea,  as  tracheotomy  would  then  be  necessary.  For  the  same 
reason  it  is  inadvisable  to  introduce  the  finger  blindly  into  the  larj^nx,  or 
to  do  anythmg  which  may  cause  a  sudden  inspiration. 

(EDEMA. 

(Edema  of  the  larynx  is  not  a  common  condition  in  early  life.  It  may 
arise  from  a  number  of  causes,  and  is  secondary  to  some  disease  elsewhere 
or  to  some  local  irritation.  It  occurs  as  a  rare  complication  in  nephritis 
and  in  the  acute  exanthemata.  It  may  arise  fi'om  irritation  produced  by 
local  lesions,  such  as  ulcerations,  from  foreign  bodies,  from  inhalations  of 
hot  vapors,  from  the  swallowing  of  corrosive  liquids,  and  also  as  the 
result  of  any  acute  inflammation,  such  as  erysipelas.  The  diagnosis,  as 
a  rule,  must  be  verified  by  a  laryngoscopic  examination. 

Treatment. — The  treatment  is  that  of  the  disease  or  local  irritation 
which  is  causing  the  oedema.  The  local  appHcation  of  cold,  and,  if  neces- 
sary, scarification  of  the  oedematous  tissue,  are  indicated.  If  the  attack 
is  pronounced  and  suffocation  is  imminent,  we  should  be  prepared  to 
perform  tracheotomy  or  intubation. 

LARYNGITIS. 

The  most  common  inflammatory  lesions  of  the  larynx  which  occur  in 
early  life  are  (1)  catarrhal  laryngitis  (false  croup,  croup)  and  (2)  pseudo- 
membranous laryngitis  (membranous  croup). 

Acute  Catarrhal  Laryng-itis  {false  croup). — The  patliological  con- 
dition which  is  present  in  the  acute  form  of  laryngitis  is  a  redness  or 
hyperasmia  of  the  laryngeal  mucous  membrane,  accompanied  by  more  or 
less  swelling  and  serous  exudation.  The  cause  of  acute  catarrhal  laryn- 
gitis is  often  a  simple  extension  of  a  catarrhal  condition  of  the  nose  and 
pharj'nx  to  the  larynx.  More  rarely  a  catarrhal  condition  of  the  bronchi 
and  trachea  may  extend  upward  and  involve  the  lan^nx.  At  tunes  the 
condition  appears  to  be  the  result  of  atmospheric  changes  and  undue 
exposure  to  dampness  and  cold.  The  lumen  of  the  larynx  in  infancy 
and  m  early  childhood  is  so  small  that  even  a  moderate  swelling  of  the 
laryngeal  mucous  membrane  may  produce  sufficient  stenosis  to  give  rise 
to  marked  obstructive  symptoms. 

Symptoms. — The  symptoms  of  acute  lan^ngitis  are  a  heightened 
temperature,  38.3°,  38.8°.  39.4°  C.  (101°,  102°,  103°  F.),  and  even 
higher,  hoarseness  and  cough.  These  symptoms,  occurring  in  connec- 
tion with  a  preceding  rhinitis  or  pharyngitis,  or  arising  from  a  primary 
inflammation  of  the  larj^nx,  may  continue  for  a  number  of  days  without 
any  more  serious  manifestations,  and  if  the  child  is  kept  in  an  equable 
temperature  the  attack  may  pass  off  within  a  week.     In  some   cases, 


662  PEDIATRICS. 

however,  another  set  of  symptoms  may  appear  after  the  primary  mani- 
festations have  lasted  for  a  variable  period.  The  child  may  be  as  well 
as  usual  in  the  morning.  Towards  the  latter  part  of  the  day  its  voice 
becomes  hoarse  and  there  is  a  slight  cough,  but  without  any  other  symp- 
toms of  special  importance.  After  being  restless  for  a  time  it  suddenly 
awakes,  and  springs  up  in  bed  frightened,  often  clutching  at  its  throat  as 
if  it  had  a  sensation  of  suffocation.  The  cough,  which  during  the  day 
was  hoarse  and  somewhat  metallic,  is  now  loud  and  rasping.  The  child 
has  difficulty  in  breathing,  amounting  to  orthopnoea,  and  its  face  is  con- 
gested. These  symptoms  continue  for  a  variable  period  ;  usually  they  last 
for  only  one  or  two  hours,  but  rarely  may  continue  for  many  hours.  In 
one  very  uncommon  case  which  was  under  my  care  the  attack  lasted  for 
three  or  four  weeks,  during  which  time  it  often  seemed  as  though  suffo- 
cation was  imminent.  There  Avas  in  this  case  no  evidence  of  any  lesion 
beyond  a  catarrhal  laryngitis,  and  recovery  finally  took  place.  These 
attacks  are  partly  due  to  obstruction  in  the  larynx  from  the  swollen 
mucous  membrane,  the  seat  of  the  swelling  in  these  cases  being  sub- 
glottic, but  they  are  largely  the  result  of  a  neurosis  due  to  a  highly  sen- 
sitive condition  of  the  mucous  membrane.  On  the  following  day  the 
hoarseness  may  continue,  but  the  child  seems  bright  and  plays  about  as 
usual.  It  is  very  common  for  the  attack  to  recur  on  the  second  night 
with  greater  severity,  but  in  certain  cases  one  attack  terminates  the  dis- 
ease, and  after  a  variable  number  of  days,  the  voice  becoming  clearer 
each  day  and  the  temperature  returning  to  normal,  the  child  recovers. 
Children  who  have  once  had  attacks  of  this  kind  are  liable  to  have  recur- 
rences until  they  grow  older. 

Diagnosis. — The  diagnosis  of  acute  catarrhal  laryngitis  is  to  be  made 
from  foreign  bodies  in  the  larynx,  traumata,  and  membranous  laryngitis. 
The  symptoms  in  the  first  two  are  not  preceded  by  catarrhal  symptoms 
elsewhere,  which  are  almost  always  met  with  in  catarrhal  laryngitis.  In 
a  typical  case  of  acute  catarrhal  laryngitis  with  suffocative  symptoms  the 
-diagnosis  is  not  difficult.  The  acute,  sudden  onset  of  the  attack  in  the 
night,  the  loud,  metallic  cough,  and  the  heightened  temperature,  are  dis- 
tinct from  the  moderate  temperature  and  the  slow,  progressive  stenosis 
caused  by  the  formation  of  a  membrane  in  the  larynx. 

Prognosis. — Acute  laryngitis  is  a  self-limited  disease,  and  one  in  which 
the  prognosis  is  almost  invariably  good.  In  children  who  are  very  weak 
and  debilitated  the  interference  with  their  respiration  may  prove  to  be 
serious,  but  these  cases  are  rare  and  should  be  treated  with  stimulants 
until  the  disease  has  run  its  course.  The  symptoms  of  acute  catarrhal 
laryngitis  are  so  terrifying  to  the  parents  that  the  physician  is  often  led  to 
look  upon  the  disease  more  seriously  than  is  necessary. 

Treatment. — The  treatment  of  acute  catarrhal  laryngitis  is  to  keep  the 
child  in  a  room  of  an  equable  temperature  of  about  20°  to  21°  C.  (68° 
to  70°  F.)  until  its  temperature  has  become  normal  and  the  hoarseness 


DISEASES    OF   THE    MOUTH.  663 

has  disappeared.  We  have  also  found  that  a  few  drops  of  wine  of  ipecac, 
given  in  the  latter  part  of  the  afternoon  and  just  as  the  child  is  going  to 
sleep,  are  of  benefit  in  preventing  the  spasmodic,  obstructive  symptoms 
which  have  just  been  described  as  occumng  in  the  night.  ^Vhen  the  attack 
occurs  in  the  night  the  symptoms  of  suffocation  can  be  best  relieved  by  a 
dose  of  from  five  to  ten  minims  of  wine  of  ipecac,  or  an  amount  suffi- 
cient to  nauseate  slightly.  An  emetic  will  sometimes  cut  short  an  attack 
of  this  nature,  but  in  many  cases  is  not  necessan*.  An  amount  of  ipecac 
sufficient  to  nauseate  slightly,  but  not  to  cause  the  child  to  vomit,  will 
often  so  relax  the  spasm  of  the  larjTix  that  the  attack  ^vill  soon  be  relieved. 
In  many  cases,  however,  even  if  vomiting  has  been  produced,  the  attack 
continues,  and  other  measures  for  relief  are  required.  In  addition  to  the 
ipecac,  moderate  doses  of  tinctura  opii  camphorata,  0.3  to  0.6  c.c.  (5  to 
10  minims),  may  be  given.  An  atmosphere  of  steam  usually  gives  great 
relief  to  the  spasm.  Many  accidents  have  occurred  from  the  improper 
management  of  the  steam  and  from  giving  such  emetics  as  turpeth  mineral. 
The  necessity  for  operative  measures  rarely  arises. 

Chronic  Laryngitis. — A  chronic  form  of  laryngitis  occurs  in  both 
infants  and  children.  Syphilitic  infants  are  at  times  affected  by  chronic 
larjmgitis.  It  may  also  occur  in  tubercular  disease,  but  is  not  common. 
When  an  acute  laryngitis  has  occurred  a  number  of  times,  or  when  an 
attack  has  been  much  prolonged  by  improper  treatment,  chronic  larjmgitis 
may  result.  In  many  of  these  cases  the  voice,  on  the  slightest  exposure 
to  dampness,  becomes  hoarse,  and  this  hoarseness,  after  a  time,  may  be 
continuous. 

Treatment. — The  treatment  is  to  apply  astringents  to  the  pharynx, 
which  is  almost  universally  involved,  and  to  regulate  the  climatic  sur- 
rounduigs  of  the  child.  Local  apphcations  to  the  larynx  in  these  cases 
are  seldom  necessary. 

Pseudo -Membranous  Laryngitis. — A  pseudo-membrane  in  the  larj'nx 
may  be  caused  by  the  inhalation  of  irritating  vapors,  or  by  the  inspiration 
of  corrosive  liquids.  These  accidents  are  so  readily  recognized  that  there 
is  no  difficulty  in  determining  the  cause  of  the  pseudo-membrane  in  these 
cases.  Treatment  for  the  relief  of  the  stenosis  should  be  instituted  at 
once.  This  consists  in  the  application  of  cold  and  such  soothing  inhala- 
tions as  3.75  c.c.  (1  drachm)  of  compound  tincture  of  benzoin  m  a  quart 
of  boiling  water.  The  complicating  oedema  which  is  often  present  in 
these  cases  may  require  operative  interference. 

The  most  common  cause  of  pseudo-membranous  laryngitis,  and  the 
one  which  probably  in  nearly  all  cases  produces  it,  is  some  form  of  micro- 
organism. These  micro-organisms  may  be  of  several  varieties.  Until  it 
is  proved  not  to  be  so,  however,  pseudo-membranous  laryngitis  must  be 
looked  upon  clinically  as  infectious  and  due  most  commonly  to  the  Klebs- 
Loeffier  bacillus.  There  is  no  doubt  but  that  a  simple  catarrhal  inflam- 
mation localized  in  the  larynx  may  be  produced  by  the  Klebs-Loeffler 


664  PEDIATRICS. 

bacillus.    The  symptoms,  diagnosis,  and  treatment  of  laryngeal  diphtheria 
have  been  described  on  page  458. 

Some  aid  in  the  differential  diagnosis  of  pseudo-membranous  from 
acute  catarrhal  laryngitis  can  be  obtained  from  the  temperature,  which  in 
the  latter  is  considerably  raised,  while  in  the  former  it  is  moderate  and 
sometunes  normal  or  subnormal.  The  slow  course  of  a  constitutional 
disease  gradually  causing  obstruction  is  significant  of  this  infectious  form 
of  laryngitis. 

DISEASES  OF  THE  TRACHEA. 

Pathological  conditions  of  the  trachea  not  connected  with  those  of  the 
air-passage  above  or  below  it  are  uncommon.  The  lesions  of  the  trachea 
may  be  primary  or  secondary.  In  the  latter  they  are  merely  an  extension 
of  the  disease  from  the  larynx  or  the  bronchi,  and  do  not  play  an  es- 
pecially significant  part  in  the  attack.  The  only  primary  disease  of  the 
trachea  w^hich  is  common  in  infancy  and  childhood  is  an  acute  inflamma- 
tion occurring  in  its  mucous  lining.  When  this  inflammatory  condition 
is  present,  it  produces  an  irritating  cough  w- hich  can  usually  be  excited  by 
gentle  pressure  over  the  trachea, — about  the  only  method  by  which  we 
can  locate  the  disturbance. 

The  treatment  is  to  protect  the  child  from  an  atmosphere  which  is 
either  too  hot  or  too  cold,  from  high  winds,  and  from  dust.  Douching 
the  front  of  the  neck  with  cold  water  several  times  during  the  day  is  also 
desirable.  Direct  applications  to  the  trachea  are  almost  impossible  in 
young  children. 

DISEASES  OF  THE  BRONCHI  AND  LUNGS. 

The  diseases  which  affect  the  lungs  in  infancy  and  childhood  differ 
somewhat  from  the  same  diseases  occurring  in  later  life,  on  account  of  the 
differences  which  exist  in  the  anatomical  conditions  at  birth  and  durin? 
_the  early  years  of  life,  especially  the  first  five.  The  principle  differences 
are  that  the  bronchi  occupy  a  relatively  larger  portion  of  the  lung  in  the 
child  than  in  the  adult,  that  in  the  former  the  interstitial  tissue  is  present 
in  a  larger  amount,  that  the  cavities  of  the  air-vesicles  are  smaller,  and 
that  their  w^alls  are  relatively  thicker ;  also  that  the  epithelial  cells  lining 
the  air-vesicles  are  very  numerous.  These  cells  in  inflammation  tend  to 
rapid  cell-division,  which  is  one  of  the  characteristics  that  mark  the  pneu- 
monia of  childhood.  These  anatomical  differences  are  of  great  signifi- 
cance w^hen  any  part  of  the  lung  is  diseased,  and  tend  to  make  a  con- 
gested lung  of  much  more  serious  import  in  the  young  child  than  in  the 
adult.  Post-mortem  examinations  often  show^  various  lesions  which 
during  life  were  not  represented  by  any  definite  symptoms,  so  that  w^e 
cannot  expect  the  clinical  diagnosis  to  include  entirely  the  pathological 
lesions. 


DISEASES  OF    THE    BRONCHI   AND    LUNGS.  665 

ACUTE  BRONCHITIS. 

By  bronchitis  we  mean  an  inflammation  of  both  the  large  and  the  small 
bronchi,  with  the  exception  of  the  ultimate  divisions  which  lead  directly 
into  the  alveoli,  and  which  probably  are  never  affected  without  involving 
the  alveoli  also.     The  disease  may  be  acute  or  chronic. 

Etiology. — Bronchitis  is  often  secondary  to  some  other  disease,  or  to 
a  direct  extension  from  an  inflammatory  condition  of  the  upper  air-pas- 
sages. In  a  number  of  cases,  however,  the  group  of  symptoms  by  which 
we  determine  that  bronchitis  is  present  is  so  prominent  from  the  very 
beginning  of  the  attack  that  clinically  we  can  describe  a  primary  bron- 
chitis. 

The  anatomical  peculiarities  of  the  mucous  membrane  lining  the 
bronchial  tubes — namely,  the  prominence  of  its  capillaries  and  its  com- 
paratively loose  connection  with  the  muscular  walls — render  the  bronchial 
mucous  membrane  peculiarly  susceptible  to  congestion.  Exposure  to 
sudden  atmospheric  changes,  especially  humidity,  appears  to  be  of  great 
etiological  importance  in  the  production  of  bronchitis.  Any  impurity  of 
an  irritating  nature  in  the  inspired  air  may  in  certain  individuals  result  in 
an  attack  of  bronchitis.  A  catarrhal  inflammation  of  the  upper  air-pas- 
sages is  often  followed  by  a  similar  inflammation  of  the  bronchia.1  mucous 
membrane.  Bronchitis  is  of  frequent  occurrence  in  pertussis  and  measles. 
It  is  in  children  often  a  prominent  symptom  of  typhoid  fever,  and  is  a 
frequent  complication  of  pulmonary  tuberculosis  and  epidemic  influenza. 
There  are  also  certain  diseases  of  nutrition  in  which  bronchitis  frequently 
occurs.  The  most  prominent  of  these  is  rhachitis,  in  which  the  com- 
plication of  bronchitis  is  often  of  serious  miport. 

Pathological  Anatomy. — The  pathological  conditions  which  are  present 
in  acute  catarrhal  bronchitis  are  a  congestion  and  swelling  of  the  mucous 
membrane  and  an  arrest  of  the  functions  of  the  mucous  glands.  Later,  the 
mucous  glands  resume  their  functions  with  increased  activity,  the  con- 
gestion diminishes,  there  is  an  increased  desquamation  of  epithelium,  an 
increased  formation  of  the  deeper  epithelial  cells,  a  moderate  emigration 
of  white  blood-cells,  and  sometimes  the  red  blood-cells  also  escape  through 
the  vessels.  The  whole  process  is  a  superficial  one,  and  does  not  produce 
any  change  in  the  walls  of  the  bronchi  beneath  the  mucous  membrane, 
unless  it  has  persisted  for  some  time,  when  there  may  be  a  slight  thick- 
ening of  the  walls.  When  the  mflammation  involves  the  smaller  bronchi 
they  may  be  occluded.  The  occlusion  of  the  smaller  bronchi  may  result 
in  the  collapse  of  the  group  of  air-vesicles  to  which  they  lead,  and  thus 
areas  of  atelectasis  will  be  produced,  which  may  be  further  changed  by 
mflammatory  processes.  The  bronchial  nodes  are  frequently  enlarged, 
even  in  mild  attacks  of  bronchitis. 

Fig.  142  represents  the  section  of  a  child's  lung,  made  by  Northrup. 
It  shows  the  exudative  inflammation  of  the  bronchi  which  occurs  in  acute 


666  PEDIATRICS. 

bronchitis.  The  specimen  shows  hyperplasia  of  the  lymph-nodes  due  to 
bronchitis.  This  condition  is  very  commonly  found  in  bronchitis,  espe- 
cially when  it  occurs  in  debilitated  children.  There  is  desquamation  of 
the  epithelium  lining  the  bronchi,  as  well  as  a  slight  thickening  of  their 
walls. 

Symptoms. — The  onset  of  acute  bronchitis  is  usually  mild,  but  I  have 
seen  in  a  debilitated  infant  a  simple,  uncomplicated  bronchitis  begin  with 
a  convulsion.  The  symptoms  are  very  variable  in  their  intensity,  and 
are  usually  more  acute  and  definite  in  a  previously  healthy  child  than 
m  debilitated  children,  in  whom  they  are  often  subacute  and  of  an  in- 
sidious nature.  In  infants  and  young  children  the  bronchitis  is  almost 
always  preceded  by  a  catarrhal  condition  of  the  upper  air-passages.     In 

Pio.   142. 


Br.,  bronchus;  Art.,  artery;  Lym.  Gi.,  lympn-node. 


the  mild  cases  there  is  an  elevation  of  the  temperature,  37.7°  to  38.3°  C. 
(100°  to  101°  F.),  cough  of  greater  or  less  severity,  and  a  slight  lessen- 
ing of  the  appetite.  On  physical  examination  the  pulmonary  resonance 
is  found  to  be  normal.  A  few  sibilant  and  sonorous  rales  are  heard  with 
especial  frequency  in  the  area  between  the  scapula  and  the  vertebral 
column.  Moist  rales  may  also  be  heard.  In  severe  cases  the  children 
suffer  from  more  or  less  discomfort,  produced  probably  by  the  thoracic 
pain,  although  in  young  children  the  locality  of  the  pain  cannot,  as  a 
rule,  be  determined.  The  cough  is  hard  and  dry,  the  respirations  may 
be  slighly  raised,  and  the  pulse  accelerated.  The  children  may  appear 
quite  ill  for  two  or  three  days,  and  the  temperature  may  rise  as  high  as 
38.8°  or  39.1°  C.  (102°  or  102.5°  F.) ;  but  when  this  latter  point  is 
reached  the  onset  of  a  broncho-pneumonia  should  be  carefully  watched 


DISEASES   OF   THE   BROXCHI   AND   LUXGS.  667 

for,  especially  if  after  from  twenty-four  to  forty-eight  hours  the  tempera- 
ture does  not  fall  to  37.7°  or  38.3°  C.  (100°  or  101°  F.) 

After  a  few  days  the  severity  of  the  symptoms  lessens,  the  cough  be- 
comes looser,  the  rales  gradually  disappear,  and  under  favorable  condi- 
tions the  symptoms  subside  entirely  in  a  week  or  ten  days.  There  is 
seldom  any  expectoration  in  children  under  six  or  seven  years.  In  the 
more  severe  cases  the  rales  are  more  numerous  than  m  the  mild  form  of 
the  disease,  but  are  of  the  same  character.  In  the  course  of  some'  cases 
of  bronchitis  a  temporary  localized  diminution  or  even  absence  of  the 
respiratory  sound  may  result  from  the  occlusion  of  a  bronchus.  Tliis  is 
especially  common  in  infants,  and  ordinarily  is  not  accompanied  by  a 
change  in  the  percussion-sound.  This  form  of  bronchitis  is  the  one 
which  affects  the  larger  and  the  medium-sized  bronchi. 

There  is  no  characteristic  temperature  in  bronchitis.  As  a  rule,  it  is 
moderate,  37.2°  to  38.3°  C.  (99°  to  101°  F.)  but  it  varies  greatly  accord- 
ing to  the  individual  and  to  the  degree  of  nervous  excitement. 

The  blood  shows  nothing  of  diagnostic  value  (Cabot).  Leucocytosis 
is  not  present  in  the  usual  forms  of  acute  bronchitis,  but  only  in  the  so- 
called  capillary  bronchitis  (broncho-pneumonia)-,  in  which  a  leucocytosis 
is  usually  present. 

Diagnosis. — The  diagnosis  of  the  ordman-  cases  of  acute  bronchitis, 
in  which  only  the  lai^e  and  medium-sized  bronchi  are  affected,  is  not  diffi- 
cult, the  only  disease  for  which  it  is  likely  to  be  mistaken  being  broncho- 
pneumonia. In  this' latter  disease  the  greater  severity  of  the  symptoms 
and  the  higher  temperature  will  usually  show  its  presence,  even  though 
the  physical  signs  may  be  only  those  described  as  occurring  in  bronchitis. 
In  the  more  severe  forms  of  bronchitis  it  is  sometimes  exceedingly  diffi- 
cult to  make  the  differential  diagnosis  from  broncho-pneumonia.  If, 
how-ever,  the  temperature,  after  three  or  four  days,  remains  high,  and 
rises  to  39.1°  or  39.4°  C.  (102.5°  or  103°  F.),  with  marked  remissions 
and  exacerbations,  the  diagnosis  becomes  doubtful,  and  in  these  cases  we 
should  strongly  suspect  that  a  broncho-pneumonia  has  arisen  as  a  com- 
plication. We  must,  however,  remember  that  in  certain  cases  of  broncho- 
pneumonia the  temperature  may  be  as  moderate  as  in  acute  bronchitis, 
and  we  must  therefore  rely  on  a  combination  of  symptoms  rather  than 
on  any  one  symptom  or  sign.  An  important  point  in  the  differential 
diagnosis  between  bronchitis  and  broncho-pneumonia  is  that  the  physical 
signs  in  the  former  are  much  more  frequently  found  in  all  parts  of  the 
thorax,  while  in  the  latter  circumscribed  groups  of  rales  are  often  de- 
tected in  different  parts  of  the  lungs.  The  rales  in  themselves,  however, 
are  not  distinctive,  as  the  rales  in  broncho-pneumonia  are  mostly  those 
of  the  accompanying  bronchitis.  Although  the  physical  signs  of  dulness 
and  bronchial  respiration  are  conclusive  evidences  that  the  case  is  not  one 
of  bronchitis  alone,  yet  an  absence  of  these  signs  does  not  justify  us  in 
excluding  broncho-pneumonia.     When  the  dyspnoea,  general  prostration, 


668  PEDIATRICS. 

and  restlessness  are  slight  and  the  temperature  moderate,  the  case  is 
likely  to  be  one  of  bronchitis,  while  if  these  symptoms  are  marked,  and 
are  combined  with  cyanosis,  dilatation  of  the  alse  nasi,  and  a  higher  tem- 
perature, at  least  a  provisional  diagnosis  of  broncho-pneumonia  should  be 
made.  In  some  cases  the  differential  diagnosis  will  also  have  to  be  made 
from  the  onset  of  a  pleuritis  or  of  a  lobar  pneumonia,  but  the  moderate 
temperature  and  respirations,  the  normal  percussion-sounds,  and  the 
diffuse  bilateral  rales  in  bronchitis  usually  make  the  diagnosis  from  these 
diseases  cphte  evident.  If  the  blood-count  shows  an  absence  of  leuco- 
cytosis  it  favors  the  diagnosis  of  bronchitis. 

Prognosis. — The  prognosis,  when  no  complication  arises  and  the  child 
is  previously  healthy,  is  good.  In  debilitated  children,  and  especially 
when  rhachitis  is  present,  even  a  mild  form  of  bronchitis  may  prove  to  be 
serious,  on  account  of  the  danger  of  a  complicating  broncho-pneumonia, 
and  in  these  cases  the  prognosis  is  much  more  unfavorable. 

Treatment. — The  treatment  of  acute  bronchitis  is  essentially  hygienic. 
The  child  should  be  confined  to  a  warm,  well-ventilated  room  which  has 
a  sunny  exposure,  and  which  is  heated  by  an  open  fire  to  a  temperature 
of  about  20°  to  21.1°  C.  (68°  to  70°  F.).  A  few  mmims  of  wine  of 
ipecac  should  be  given  if  the  cough  is  unusually  dry,  and  to  this  a  few 
minims  of  tinctura  opii  camphorata  may  be  added  if  the  patient  is  very 
nervous.  These  remedies  are  all  that  will  usually  be  needed  in  an  attack 
of  acute  bronchitis.  When  a  rhachitic  child  or  one  who  is  much  debili- 
tated is  attacked  by  the  disease,  especial  care  must  be  taken  to  support  its 
strength  by  stimulants  and  food. 

Unusual  Form  of  Acute  Bronchitis. — Besides  the  acute  bronchitis 
just  described,  we  have  met  with  a  class  of  cases  which  are  extremely  rare, 
but  which,  apparently,  are  instances  of  an  exacerbation  of  an  ordinary 
bronchitis  through  the  involvement  of  the  smaller  bronchi,  not  the  terminal 
ones.     We  have  seen  only  six  or  eight  of  these  cases.     These,  from  their 
clinical  history,  seem  to  have  been  cases  of  bronchitis  rather  than  of 
broncho-pneumonia.    We  speak  of  them  separately,  as  the  symptoms  differ 
somewhat  from  those  of  an  ordinary  bronchitis.     This  form  of  bron- 
chitis has  no  connection  with  that  which  was  formerly  erroneously  called 
capillary  bronchitis,  but  which  is  well  known  to  be  only  an  early  stage  of 
broncho-pneumonia.     This  form  of  bronchitis  in  our  cases  has  commonly 
occurred  in  infants  in  the  first  two  years  of  life,  though  we  have  met  with 
it  as  late  as  the  third  year.     The  cause,  so  far  as  could  be  ascertained, 
was  the  same  as  in  an  ordinary  bronchitis,  a  catarrhal  condition  of  the 
upper  air-passages  usually  preceding  the  attack.     The  onset  of  the  disease 
was  rapid,  and  the  symptoms  soon  became  very  severe.     The  tempera- 
ture was,  as  a  rule,  moderately  raised,  37.7°  to  38.3°  C.  (100°  to  101° 
F.).     The  cough  was  continuous,  and  dyspnoea,  with  more  or  less  cy- 
anosis, rapidly  developed.     An  examination  showed  normal  resonance 
throughout  the  whole  thorax,  and  fine  moist  rales.    The  respirations  were 


DISEASES   OF   THE   BRONCHI   AND    LUNGS.  669 

rapid,  the  pulse  was  accelerated,  and  all  the  symptoms  were  of  a  violent 
and  suffocative  nature.  The  infants  were  much  distressed,  and  were  un- 
willing to  be  laid  down.  After  from  twenty-four  to  forty-eight  hours  the 
symptoms  grew  less  severe,  the  temperature  became  normal  or  was 
only  slightly  raised,  and  the  fine  moist  rales  were  replaced  by  coarse 
moist  rales  and  the  sibilant  and  sonorous  rales  of  an  ordinary  bronchitis 
of  the  larger  and  the  medium-sized  bronchi. 

Diagnosis. — This  form  of  bronchitis  is  to  be  differentiated  from  broncho- 
pneumonia. The  temperature,  instead  of  remaining  high  and  having  the 
remissions  of  a  broncho-pneumonia,  soon  falls  so  as  to  correspond  to  that 
of  an  ordinary  bronchitis.  The  physical  signs  are  those  of  bronchitis 
rather  than  of  pneumonia,  and  the  rapid  recovery  of  the  infant  with  the 
common  symptoms  of  an  ordinary  bronchitis,  rather  than  with  the  pro- 
longed and  characteristic  symptoms  of  a  broncho-pneumonia,  points 
towards  an  inflammation  of  the  smaller  bronchi.  These  cases  may  be 
complicated  with  broncho-pneumonia,  as  are  the  ordinary  cases  of 
bronchitis. 

Prognosis. — In  the  early  hours  and  days  of  the  disease,  when  the 
symptoms  are  at  their  height,  and  if  the  infant  is  weak  and  debilitated, 
the  prognosis  is  bad.  If,  however,  the  first  few  days  are  passed  in  safety, 
recovery  almost  invariably  takes  place. 

Treatment. — The  treatment  of  this  class  of  cases  is  very  important,  as 
death  from  exhaustion  is  liable  to  occur  at  any  moment.  The  extreme 
congestion  of  the  blood-vessels  of  the  smaller  bronchi  may  in  some  cases 
occlude  the  air-spaces,  and  areas  of  atelectasis  may  result.  The  indi- 
cations for  treatment  are  to  oxygenate  the  blood,  to  support  the  strength 
until  the  disease  has  run  its  course,  and  to  prevent  the  infant  from  falling 
into  a  comatose  condition.  The  treatment,  therefore,  is  the  adminis- 
tration of  oxygen,  the  use  of  stimulants,  consisting  of  aromatic  spirit  of 
ammonia  alternating  with  brandy,  and  change  of  the  position  of  the  in- 
fant from  time  to  time. 

The  following  case  illustrates  this  unusual  form  of  bronchitis : 

An  infant,  three  months  old,  had  an  attack  of  acute  bronchitis,  characterized  by  a 
paroxysmal,  dry  cough,  slightly  accelerated  respirations  and  pulse,  and  a  moderate  tem- 
perature varying  from  37.7°  to  38.3°  C.  (100°  to  101°  F.). 

The  percussion  of  the  chest  had  been  normal,  and  there  had  been  some  sonorous 
and  sibilant  rales,  with  a  few  coarse  moist  rales  heard  on  both  sides  of  the  chest. 
After  three  or  four  days  the  infant  was  attacked  with  excessive  dyspnoea  and  cyanosis. 
Its  pulse  rose  from  120  to  180,  its  respirations  from  30  to  70,  and  its  temperature 
from  37.7°  to  39.1°  C.  (100°  to  102.5°  F.).  An  examination  of  the  chest  showed 
normal  resonance  and  fine  moist  rales  throughout  both  lungs.  It  was  very  restless, 
refused  to  take  its  food,  and  evidently  wished  not  to  be  laid  down  in  its  bed,  but  to  be 
carried  about.  It  was  treated  with  alternate  doses  of  aromatic  spirit  of  ammonia  and 
brandy  every  half-hour. 

After  twenty-four  hours  the  temperature  fell  to  38°  C.  (100.5°  F.),  the  pulse  to 
150,  and  the  respirations  to  44.  The  fine  rales  were  replaced  by  the  ordinary  coarse 
rales  of  a  bronchitis,  and  the  infant  rapidly  recovered. 


670  PEDIATRICS. 

The  symptoms  and  course  of  all  these  cases  are  very  similar,  so  that  we 
shall  speak  only  of  one  other  child,  whom  we  saw  in  consultation. 

A  male,  seven  months  old,  and  previously  healthy,  for  two  days  had  a  slight 
cough,  with  a  few  sonorous  rales  in  the  chest  and  a  temperature  varying  from  36.6°  to 
37.2°  C.  (98°  to  99°  F.).  On  the  third  day  of  the  attack  he  was  suddenly  seized  with 
increased  cough,  dyspncea,  cyanosis,  respirations  of  70,  a  pulse  of  160,  and  a  tempera- 
ture of  38.3°  C.  (101°  F.).  An  examination  of  the  chest  showed  normal  resonance 
and  fine  moist  rales  throughout  both  lungs.  The  infant  was  treated  with  aromatic 
spirit  of  ammonia  and  brandy  in  alternate  doses.  On  the  following  day  the  tempera- 
ture fell  to  37°  C.  (98.6°  F.),  and  the  fine  rales  were  replaced  by  coarse  and  sonorous 
rales.     The  bronchitis  lasted  for  a  few  days,  and  the  infant  then  recovered  entirely. 

CHRONIC  BRONCHITIS. 
Etiology. — Chronic  bronchitis  may  result  from  a  series  of  attacks  of 
acute  bronchitis,  or  from  a  number  of  other  causes.     Among  these  may 
be  mentioned  various  affections  of  the  lungs,  such  diseases  connected 
with  malnutrition  as  rhachitis,  and  prolonged  attacks  of  pertussis. 

Pathological  Anatomy.  —  The  pathological  conditions  occurring  in 
chronic  bronchitis  vary  greatly  in  degree,  and  the  lesions  found  at  the 
post-mortem  examination  are  often  slight  in  comparison  with  the  severity 
of  the  symptoms  during  life.  In  most  cases  there  is  a  considerable  pro- 
duction of  mucus,  pus,  and  serum.  In  cases  which  have  lasted  for  a  long 
time,  in  addition  to  the  inflammatory  products  affecting  the  walls  of  the 
bronchi  there  may  be  dilatation  of  one  or  more  bronchi,  and  the  muscular 
coat  may  be  thickened  or  thinned.     Emphysema  may  also  result. 

Symptoms. — The  symptoms  of  chronic  bronchitis  are  very  much  the 
same  as  those  of  acute  bronchitis,  except  that  the  temperature  is  not  so 
apt  to  be  heightened,  while  the  general  symptoms  of  malaise,  anorexia, 
and  loss  of  weight  are  more  prominent.  In  severe  and  prolonged  cases 
in  which  emphysema  is  present,  the  thorax  may  assume  the  position  of 
full  inspiration,  the  ribs  being  permanently  raised  and  the  antero-posterior 
diameter  of  the  chest  increased.  The  physical  signs  are  the  same  as 
in  acute  bronchitis,  so  far  as  the  rales  are  concerned.  The  resonance  is 
usually  normal  except  when  the  chronic  process  has  produced  emphy- 
sema, in  Avhich  case  there  are  areas  of  hyper-resonance  often  associated 
with  a  tympanitic  tone.  Occasionally  atelectasis  of  considerable  areas  of 
the  lungs  may  take  place,  with  a  resulting  diminution  of  the  respiratory 
sound.  This  occurrence  may  in  some  cases  prove  to  be  serious,  but  in 
others  the  accompanying  symptoms  are  mild,  and  the  alveoli  may  again 
return  to  their  normal  degree  of  inflation. 

There  is  one  form  of  bronchitis  which  from  its  duration  may  be  called 
chronic,  and  yet  which  from  the  very  slight  degree  of  constitutional  symp- 
toms that  accompany  it  corresponds  rather  to  a  subacute  affection.  In 
these  cases,  which  usually  occur  in  infancy  and  in  early  childhood,  the 
child  often  appears  quite  well,  but  for  long  periods  of  weeks,  or  when- 


DISEASES   OF   THE   BRONCHI   AND    LUNGS.  671 

ever  it  is  exposed  to  a  damp  atmosphere,  a  loud  wheezing  will  be  heard 
in  the  ehest.  Auscultation  will  reveal  the  presence  of  sonorous  rales 
everywhere,  and  in  this  variety,  as  well  as  in  other  forms  of  chronic 
bronchitis,  a  roughened  sensation  may  sometimes  be  felt  on  palpation 
during  respiration. 

Diagnosis. — The  differential  diagnosis  is  to  be  made  from  chronic 
affections  of  the  lungs  in  which  the  thickening  of  the  interstitial  tissue 
has  taken  place  with  a  resulting  diminution  of  resonance,  and  from  the 
condition  in  which  the  bronchi  are  dilated.  In  the  latter  case  there  are 
accompanying  symptoms  of  a  profuse  exudation  of  purulent  matter. 

Chronic  bronchitis  is  also  to  be  distinguished  from  reflex  coughs  of  a 
nervous  character,  unaccompanied  by  any  disease  of  the  respiratory  tract. 
Causes  for  such  reflex  coughs  may  be  found  in  irritation  of  the  pharynx 
and  ear,  from  chronic  gastric  indigestion,  from  pulmonary  congestion, 
from  the  disturbances  in  circulation  due  to  cardiac  disease,  and,  finally, 
from  pressure  upon  the  bronchi  of  enlarged  mediastinal  lymph-nodes. 

Prognosis. — The  prognosis  of  chronic  bronchitis  varies  according  to 
the  cause.  When  it  is  secondary  to  disease  of  some  other  organ,  it 
depends  entirely  upon  the  prognosis  of  that  disease.  In  rhachitic  chil- 
dren the  prognosis  is  unfavorable,  and  in  them  a  broncho-pneumonia  is 
especially  liable  to  develop,  with  a  fatal  issue.  Cases  of  chronic  bron- 
chitis are  also  liable  to  be  invaded  by  the  tubercle  bacillus.  In  cases 
which  are  the  result  of  acute  bronchitis  in  individuals  otherwise  healthy, 
the  prognosis  is  favorable,  provided  the  proper  treatment  can  be  carried 
out.  As  emphysema  in  chronic  bronchitis  is  rare  in  children  in  com- 
parison with  adults,  the  chances  for  recovery  in  the  former  are  corre- 
spondingly good. 

Treatment. — The  treatment  of  chronic  bronchitis  is  essentially  climatic. 
The  children  should  be  kept  in  a  warm  dry  climate  for  some  months  after 
the  bronchitis  has  entirely  disappeared.  Especial  care  should  be  taken 
that  the  child  is  suitably  protected  by  flannel  undergarments.  When 
other  treatment  is  required,  as  a  rule,  tonics  will  prove  of  more  benefit 
than  the  drugs  which  are  usually  administered  for  their  direct  effect  upon 
the  bronchial  mucous  membrane. 

FrBRINOUS  BRONCHITIS. 

During  the  course  of  what  may  appear  to  be  an  ordinary  bronchitis, 
in  rare  instances  a  fibrinous  form  of  bronchitis  has  been  met  with.  In 
this  variety  masses  of  fibrin  in  the  bronchi  form  casts  of  various  extent 
according  to  the  number  of  the  bronchi  which  are  affected.  Similar 
fibrinous  casts  of  the  bronchi  may  be  found  in  cases  of  diphtheria  of  the 
larynx  by  direct  extension  to  the  bronchi,  but  do  not  represent  fibrmous 
bronchitis. 

The  disease  may  run  a  short  course  of  days  or  weeks,  but  is  usually 
chronic  and  may  last  for  years.     The  paroxysms  may  also  be  periodic. 


672  PEDIATRICS. 

The  diagnosis  can  be  made  only  when  portions  of  the  casts  have  been 
expectorated. 

Treatment. — The  treatment  is  chiefly  by  the  inhalation  of  steam  or  of 
atomized  lime-water,  and  by  supporting  the  strength  with  proper  nourish- 
ment and  stimulants  until  the  disease  has  run  its  coui"se. 

BRONCHI  AT.    ASTHMA. 

Bronchial  asthma  is  an  affection  characterized  by  spasmodic  attacks 
of  dyspnoea.  The  disease  is  rare  in  infancy,  but  is  not  uncommon  in 
childhood.  The  term  asthma  should  not  be  applied  to  dyspnoea  which 
is  dependent  upon  diseases  of  the  heart  and  kidneys. 

Etiology. — It  is  generally  accepted  that  there  is  a  strong  neurotic 
element  in  bronchial  asthma,  and  by  many  Avriters  it  is  considered  a 
neurosis.  The  most  plausible  explanation  of  the  attacks  is  the  theory 
that  it  is  due  to  a  spasm  of  the  bronchial  muscles.  Temporary  swelling 
of  the  bronchial  mucous  membrane  and  inflammation  of  the  smaller 
bronchioles,  the  bronchiolitis  exudativa  of  Curschmann,  hare  also  been 
advanced  as  possilDle  causes. 

Heredity  seems  to  be  a  factor  in  predisposing  an  individual  to  the  dis- 
ease. The  direct  exciting  causes  are  many  ;  sudden  atmospheric  changes, 
inhalation  of  irritants,  odors,  and  emanations  of  various  kinds,  frights  and 
emotions,  reflex  disturbances  in  the  nose,  upper  air-passages,  stomach, 
and  intestmes,  and  pressure  upon  the  bronchi  of  enlarged  bronchial 
lymph-nodes  may  bring  on  an  attack  in  one  who  is  predisposed  to 
them. 

Pathological  Axatomt. — Curschmann  has  described  a  peculiar  exudate 
of  mucin,  which  occurs  in  a  majority  of  cases  and  which  might  come  from 
a  turgescent  mncous  membrane,  which  gives  a  distinctive  character  to  the 
sputum.  Early  in  the  attack  it  is  expectorated  as  round,  ball-like  masses, 
which  may  be  unfolded,  representmg  casts  of  the  smaller  tubes  ;  they 
have  been  called  the  "  perles  of  Laennec."  Microscopically  these  bodies 
have  been  found  by  Curschmann  to  have  a  spiral  structure.  Within  a 
few  days  the  sputum  becomes  muco-purulent  and  the  spirals  disappear. 
These  spirals  occur  only  in  pure  bronchial  asthma,  and  not  in  bronchitis 
or  pneumonia. 

In  the  sputum  of  both  asthma  and  emphysema  the  eosinophiles  are 
very  numerous,  and  an  increase  of  the  same  cells  in  the  blood,  running 
as  high  as  14.6  per  cent.,  has  been  noticed  by  Fink.  Billmgs  reports  a  case 
in  which  the  eosinophiles  were  increased  to  53.6  per  cent.,  without  any 
increase  in  the  total  number  of  white  cells.  It  is  claimed  by  von  Woorden 
and  Schwerskewski  that  a  paroxysm  of  asthma  may  be  predicted  by  an 
increase  in  the  total  number  of  eosinophiles.  If  the  disease  is  of  long  stand- 
ing, we  may  find  an  associated  emphysema  of  the  lungs. 

Symptoms. — The  symptoms  of  bronchial  asthma  are  the  same  in  the 
child   as   in  the   adult.     A  catarrhal  condition  of  the  respiratory  tract, 


DISEASES   OF   THE    BRONCHI    AND   LUNGS.  673 

especially  of  the  bronchi,  commonly  precedes  the  attack  for  some  days. 
The  onset  is  usually  sudden,  and  generally  occurs  at  night.  The  child  is 
seized  with  distressing  dyspnoea,  mainly  expiratory,  the  respiration  being 
accompanied  by  a  wheezing  sound.  The  face  is  anxious,  and  if  the  attack 
continues  for  some  time  it  becomes  slightly  cyanotic.  The  respirations 
are  not  especially  increased  in  frequency.  The  pulse  is  rapid,  and  when 
the  dyspnoea  is  very  intense  becomes  weak.  The  temperature  is  not 
raised,  and  when  the  paroxysm  is  prolonged  it  may  become  subnormal. 
The  physical  signs  are  mostly  diffuse,  sibilant,  and  sonorous  rales,  rhonchi, 
and  muscular  rumbles,  which  obscure  or  render  inaudible  the  respiratory 
murmur.  The  attack  may  last  for  a  number  of  hours,  or  even  for  days. 
The  paroxysms  vary  in  their  severity,  and,  as  a  rule,  are  followed  by 
considerable  exhaustion.  The  frequency  of  the  attacks  varies  ;  they  may 
occur  often  or  only  at  intervals  of  months. 

Diagnosis. — Attacks  of  asthma  are  generally  easily  diagnosticated  by  the 
spasm,  the  history  of  previous  attacks,  and  the  characteristic  sputum  and 
blood.  Cardiac,  renal,  and  thyroid  dyspnoea — that  is,  conditions  known 
as  "false  asthma" — can  be  excluded  by  the  examination  of  the  blood  and 
sputum  and  by  the  recognition  of  the  respective  diseases. 

Mechanical  irritation  of  the  bronchi,  as  by  pressure  of  an  aneurism  or 
of  enlarged  glands,  may  bring  on  a  spasm  of  the  bronchioles  resembling 
true  asthma,  and  here  again  the  examination  of  the  blood  and  sputum  are 
of  great  service. 

Spasm  of  the  glottis  produces  a  noisy  dyspnoea,  but  the  difficulty  is 
with  inspiration  instead  of  expiration.  The  sound  produced  is  more  of 
a  crow  than  a  wheeze,  and  no  rales  can  be  heard  in  the  lungs. 

Prognosis. — The  prognosis  of  asthma  with  regard  to  the  especial 
attack  is  good.  When  the  disease  is  not  hereditary  the  children  very 
commonly  recover  from  it  as  they  approach  the  age  of  puberty.  In  many 
cases  the  attacks  seem  to  depend  upon  some  local  affection  of  the  air- 
passages,  and  the  cure  of  these  local  lesions  will  often  be  followed  by 
recovery  from  the  attacks  of  asthma. 

Treatment. — In  the  treatment  of  asthma,  the  nose  and  throat  should 
be  carefully  examined  for  local  diseases,  as  the  attacks  may  be  caused  by 
the  differept  forms  of  rhinitis,  adenoid  growths,  or  enlarged  tonsils.  The 
children  should  be  protected  from  unfavorable  atmospheric  influences,  a 
high,  dry,  inland  air  usually  being  better  suited  to  them  than  sea-air.  In 
some  cases,  especially  of  a  mild  form,  the  fumes  of  nitre  paper  will  give 
considerable  relief.  In  very  severe  attacks  hydrate  of  chloral  may  be 
given,  either  by  the  mouth  or  by  enemata.  Antispasmodics,  such  as  bella- 
donna and  lobelia,  can  also  be  used.  There  is  no  one  drug  which  will 
relieve  the  paroxysms  of  asthma  except  morphine,  which  should  be  used 
with  great  caution.  Iodide  of  potassium  in  gradually  increasing  doses  is 
in  some  cases  beneficial.  Especial  attention  should  be  j)aid  to  the  gen- 
eral hygiene  and  to  the  diet  of  the  child. 

43 


()74  PEDIATHICS. 

PNEUMONIA. 

Pneunioiua  is  an  acute  or  subacute  afl'ection  of  the  lungs,  due  to  the 
action  of  infectious  micro-organisms,  the  pathology,  symptoms,  and  prog- 
nosis of  which  vary  according  to  the  particular  bacterium  which  is  the 
exciting  cause  of  tlie  inflammation. 

Two  general  types  of  the  disease  are  usaally  described,  according  to 
the  mode  of  invasion  and  to  the  distribution  of  the  pathological  lesions ; 
{ly lobar 2j I leuinonku  in  which  the  whole  or  greater  part  of  a  lobe  of  the 
hmg  is  involved,  and  (2)  broncho-pneumonia^  in  which  individual  lobules 
of  the  lung  are  affected,  forming  small  areas  of  consolidation  irregularly 
distrilDuted. 

One  particular  organism,  the  pneumococcus  of  Fraenkel,  shoAvs  a  special 
tendency  to  cause  an  inflammation  of  a  lobar  type,  and  such  a  disease, 
accurately  speaking,  should  be  termed  •'•  pneuniococcv.s  lobar  pneumonia."' 
It  is  this  condition  which  is  generally  referred  to  when  the  terms  "  lobar 
pneumonia,''''  '•'■acute  croupous  pneumonia,''  or  '•acute  fibrinous  pneumonia'''' 
are  used. 

Broncho-pneumonia,  or  lobular  pneumonia,  is,  on  the  other  hand,  due  to 
a  number  of  different  organisms,  which  will  be  more  fully  described  later. 
The  especial  pomt  to  be  emphasized  in  connection  with  the  subject  of 
classification  is  the  characteristic  tendency  of  these  organisms  to  produce  an 
interstitial  inflammation  of  the  peribronchial  tissues  of  the  terminal  bronchi, 
with  exudation  into  the  neigliboring  alveoli  and  consequent  consolida- 
tion of  the  lobules  of  the  lungs.  Such  areas  of  consolidation  may  occa- 
sionally, by  confluence,  merge  into  one  large  mass,  and  end  by  producing 
a  consolidation  of  the  whole  of  a  lobe,  giving  rise  to  physical  signs  and 
sometimes  to  macroscopic  appearances  which  are  essentially  the  same  as 
a  lobar  pneumonia,  but  all  cases  of  this  variety  will,  on  microscopic  ex- 
amination, show  the  appearances  of  a  lobular  infection  differing  in  inany 
respects  from  the  microscopic  pathological  appearances  of  a  pneumococcus 
lobar  pneumonia.  Tuberculosis  of  the  lung  is  essentiallj^  a  broncho- 
pneumonia, but  with  pathological  and  clinical  features  which  are  so  dis- 
tinctive that  it  is  more  convenient  to  describe  it  in  connection  with  the 
general  subject  of  tuberculosis  (page  388). 

Both  the  lobar  and  the  lobulai*  or  broncho-pneumonias  are  diseases 
due  to  infectious  micro-organisms,  hi  view,  however,  of  the  variety  of 
etiological  factors  in  a  broncho-pneumonia,  and  of  the  occasional  cases 
which  bear  so  close  a  resemblance  to  a  lobar  pneumonia,  and  inasmuch 
as  the  specific  organism  of  pneumococcus  pneumonia  is  also,  in  a  large 
proportion  of  cases,  the  cUrect  cause  of  a  broncho-pneumonia,  it  is  much 
more  convenient  for  the  present  to  describe  these  affections  together  and 
in  connection  with  the  general  subject  of  diseases  of  the  lung.  For  the 
same  reasons  we  shall  not  attempt  to  isolate  the  pneumococcus  lobar 
pneumonia  and  to  classify  it  among  the  specific  infectious  diseases. 


DISEASES   OF   THE   BRONCHI   AND   LUNGS.  675 

FNEUMOCOOOUS  LOBAR  PNEUMONIA. 

Pneumococcus  lobar  pneumonia   is   an  acute  infectious,  self-limited 

disease,  characterized  in  typical  cases  by  sudden  onset,  high  fever,  consoli- 

'  elation  of  one  or  more  lobes  by  a  fibrinous  exudation  into  the  alveoli, 

marked  leucocytosis,  usually  running  a  course  in  children  of  from  five  to 

eight  days  and  ending  abruptly  by  crisis. 

Etiology. — Acute  infections  of  the  lungs,  wiiich  are  associated  with  a 
consolidation  of  the  Avholo  or  greater  part  of  a  lobe  of  a  lung,  are  due  in 
a  great  majority  of  cases,  probably  in  as  many  as  95  per  cent.,  to  the 
action  of  the  lyneumococevs  of  Fruenkel,  which  has  also  been  called  the 
micrococcus  lanceolatus.  This  organism  is,  at  times,  also  a  direct  cause  of 
pleurisy,  pericarditis,  endocarditis,  peritonitis,  and  meningitis. 

The  disease  is  almost  invariably  primary.  It  may  appear  in  an  epi- 
demic form  and  run  a  more  fatal  course  than  in  sporadic  cases.  It  may 
occur  at  any  age.  In  the  first  two  years  of  life  it  is  relatively  much  more 
frecjuent  than  was  formerly  supposed,  as  compared  with  broncho-pneu- 
monia, which  is  the  usual  form  of  pneumonia  in  infancy.  In  the  third 
year  it  becomes  more  common,  and,  according  to  Osier,  increases  in  fre- 
quency up  to  the  sixth  year,  when  it  diminishes  up  to  the  fifteenth  year. 
The  proporLion  of  cases  then  again  begins  to  rise.  Recurrent  attacks  of 
pneumococcus  lobar  pneumonia  are  not  so  frecfuent  in  young  children  as 
in  adults. 

Exposure  to  cold  and  especially  to  sudden  atmospheric  changes  seems 
to  render  the  individual  more  susceptible  to  the  invasion  of  the  micro- 
organism. When  this  form  of  pneumonia  occurs,  as  it  sometimes  does, 
as  a  secondary  infection  in  such  diseases  as  pertussis,  measles,  and  scarlet 
fever,  it  is  usually  in  children  over  three  years  of  age.  These  secondary 
pneumonias  are,  however,  much  more  likely  to  be  in  the  nature  of 
broncho-pneumonia. 

Pneumonia  is  not  a  contagious  disease  in  the  ordinary  sense,  but  infec- 
tion may  be  spread  or  be  incurred  by  attendants  from  contact  with  the 
excretions,  especially  with  the  sputum,  which  should  always  be  carefully 
collected  and  disinfected  with  precautions  similar  to  those  used  in  pulmon- 
ary tuberculosis. 

Pathological  Anatomy. — The  pathological  condition  which  occurs  in 
lobar  pneumonia  is  an  acute  exudative  inflammation  which  involves  pro- 
gressively the  whole  of  one  lobe,  or  the  larger  part  of  one  lu^ig,  or  por- 
tions of  both  lungs.  There  is  no  especial  distinction  between  the  lesions 
of  lobar  pneumonia  as  they  occur  in  children  and  those  which  are  met 
with  in  adults,  except  so  far  as  the  anatomical  conditions  differ  according 
to  the  age  of  the  individual.  It  is  much  more  common,  however,  to  have 
the  pneumonic  process  begin  in  the  apices  of  the  lungs  in  children  than 
in  adults.  Statistics  show  that  both  lungs  are  affected  with  about  the 
same  frequency,  and  that  the  order  of  frequency  is  left  base,  right  apex, 
right  base,  left  apex. 


676  PEDIATRICS. 

The  stages  of  congestion,  red  hepatizotion,  gray  hepatization,  and  reso- 
lution take  place  in  succession  in  the  pneumonia  of  the  child  as  in  that 
of  the  adult.  In  the  stage  of  congestion  the  lung  is  hypergemic  and 
(.edematous  and  the  air-vesicles  contain  fibrin,  pus,  granular  matter,  red 
blood-cells  and  epithelial  cells.  The  epithelium  of  the  air-vesicles  is 
swollen,  and  there  are  large  numbers  of  white  blood-cells  in  the  capil- 
laries. The  large  bronchi  are  congested.  The  small  bronchi  contain  the 
same  inflammatory  products  as  do  the  air-vesicles.  This  stage  lasts  only 
a  few  hours,  as  a  rule,  but  may  be  protracted  for  several  days.  When 
the  exudation  of  the  inflammatory  products  has  reached  its  full  develop- 
ment the  presence  of  these  products  within  the  air-vesicles  and  bronchi 
causes  the  lung  to  be  slightly  enlarged,  and  at  this  time  it  is  said  to  be  in 
the  condition  of  red  hepatization.  After  the  air-vesicles  have  become 
completely  filled  with  exudation  there  follows  a  period  during  which  the 
exudation  first  becomes  decolorized  and  then  degenerated.  This  is  the 
period  of  gray  hepatization.  This  happens  at  a  variable  time,  which  is 
usually  shorter  in  children  than  in  adults.  The  color  finally  becomes 
gray.  The  exudate  then  undergoes  still  further  degeneration  and  soften- 
ing, and  is  removed  by  the  lymphatics.  This  is  the  stage  of  resolution. 
Resolution  usually  begins  immediately  after  defervescence  and  is  com- 
pleted within  a  few  days,  but  it  may  not  begin  until  a  number  of  days 
after  defervescence,  and  may  be  unusually  protracted. 

The  bronchi  are  almost  always  affected  in  lobar  pneumonia.  The 
pneumonic  process  may  occur  in  small  patches,  but  usually  involves  an 
entire  lobe.  The  left  lower  lobe  is  most  frequently  affected  in  early  life, 
but  the  locality  of  the  pneumonia  is  of  pathological  rather  than  of  clinical 
importance,  as  the  disease  may  attack  any  part  of  the  lungs.  It  is  generally 
an  unilateral  disease,  but  in  some  cases  it  may  be  bilateral. 

Symptoms. — The  onset  of  a  pneumococcus  lobar  pneumonia  is,  as  a 
rule,  very  acute,  and  in  the  infant  or  young  child  is  frequently  ushered  in 
by  vomiting  and  rarely  by  convulsions.  The  temperature  rises  suddenly 
_aiid  remains  high,  as  a  rule,  until  the  crisis.  The  pulse-rate  is  increased. 
The  child  appears  profoundly  infected.  The  face  is  flushed,  the  skin  hot 
and  dry.  The  cough  is  short,  dry,  and  painful.  The  respirations  are 
rapid  and  shallow.  The  al«  nasi  expand  with  each  inspiration,  and  the 
dyspnoea  is  marked.  The  mind  at  first  is  clear,  but  as  the  process  con- 
tinues delirium  and  stupor  assert  themselves  as  prominent  symptoms.  In 
from  five  to  eight  days  the  disease  in  typical  cases  runs  its  course.  The 
temperature  falls  by  crisis.  Sometimes  within  a  few  hours  the  picture 
changes  suddenly.  The  breathing  becomes  easy,  the  skin  moist  and  then 
bathed  in  perspiration,  the  pulse  slow  and  full,  the  appetite  returns,  and 
convalescence,  barring  complications,  is  rapid. 

The  individual  symptoms  vary  so  greatly  in  different  cases  that  they 
can  be  understood  best  when  considered  separately. 

Onset. — The  onset  of  the  disease  is  preceded  by  a  prodromal  stage  of  a 


DISEASES    OF   THE    BRONCHI   AND   LUNGS.  677 

few  hours  only,  sometimes  with  mild  catarrhal  symptoms,  sometimes  with 
only  chilly  sensations,  headache,  and  malaise.  Fever,  cough,  apathy  and 
drowsiness  are  the  usual  early  symptoms.  A  definite  rigor  is  very  un- 
common under  five  years  ;  convulsions,  although  rare,  are  more  frequent 
in  infants  and  are  uncommon  at  a  later  period.  Vomiting  or  diarrhoea, 
especially  in  summer,  are  common.  Pain  is  a  fairly  constant  initial  symp- 
tom, but  the  younger  the  child  the  less  definitely  is  it  localized ;  it  is  often 
referred  to  the  abdomen,  and  may  suggest  the  pain  which  occurs  in  the 
beginning  of  an  appendicitis.     The  prostration  is  pronounced. 

Tenvperature. — The  temperature  rises  suddenly  to  39.4°,  40°,  or  40.5° 
C.  (103°,  104°,  or  105°  F.) ;  it  remains  high,  with  variations  of  one  or 
two  degrees  in  the  morning  and  evening  observations.  Within  these 
limits  of  temperature  the  prognosis  is  not  influenced  by  the  height  of  the 
fever.  The  cases  with  a  short  duration  are  more  likely  to  occur  in  the 
first  year.  At  times  the  variations  are  much  greater  than  this.  In  typical 
cases  the  temperature  drops  to  normal  with  a  distinct  crisis,  and  rises 
again  only  in  the  case  of  reinfection  or  of  a  complication. 

Pulse. — The  pulse  is  full  and  bounding  at  first,  and  somewhat  accel- 
erated, averaging  between  150  and  170.  As  the  toxins  accumulate  its  rate 
increases,  the  tension  diminishes,  and  the  weakening  of  the  heart  is  indi- 
cated by  a  small,  rapid,  irregular,  intermitting,  or  dicrotic  pulse,  with 
cyanosis  and  jugular  pulsation. 

Respiration. — The  respirations  are  always  greatly  increased,  the  average 
being  between  55  and  80,  the  alse  nisi  dilate  in  inspiration,  and  dyspnoea 
is  manifested  by  short,  labored,  jerky  breathing.  The  normal  ratio  be- 
tween the  pulse  and  respiration  is  greatly  disturbed,  and  constitutes  one 
of  the  chief  features  of  the  disease.  Instead  of  being  in  the  ratio  of  1  to  3 
or  4  it  may  be  as  great  as  1  to  2.  Respirations  of  60  to  70  to  a  pulse  of 
12'J  to  140  is  not  uncommon  in  children.  That  this  remarkable  dis- 
turbance is  not  dependent  upon  the  consolidation  alone  is  evident  by  the 
change  in  the  type  of  respiration  and  pulse  which  occurs  after  a  crisis, 
when  the  signs  of  consolidation  remain  the  same.  Cases  in  Avhich  the 
respiration  was  over  90  have  recovered. 

Cerebral  Symptoms. — In  some  cases  during  the  height  of  the  disease 
there  is  delirium.  In  the  milder  cases  the  delirium  may  be  merely  a 
slight  wandering,  but  in  the  more  severe  cases  the  children  may  become 
much  excited,  and  the  delirium  may  be  accompanied  by  contracted  or 
dilated  pupils,  and  even  involuntary  passages  of  urine  and  of  faeces,  with 
continual  movement  of  the  head,  muscular  twitchings,  retraction  of  the 
head,  and  other  symptoms  which  may  simulate  closely  those  of  cerebro- 
spinal meningitis.  In  place  of  the  delirium  and  the  excited  condition  there 
may  be  a  condition  of  stupor  whicli  sometimes  simulates  that  of  tubercular 
meningitis.  In  another  set  of  cases  the  nervous  symptoms  markedly 
simulate  those  of  the  non-tubercular  form  of  meningitis.  Meningitis, 
however,  may  sometimes  actually  occur  in  the    course  of  pneumonia, 


678  PEDIATKK'^. 

and  be  due  to  a  pneumococcus  infection.  Violence  of  the  symptoms  is  not 
common.  Marked  cerebral  sj'mptoms  seem  to  depend  more  on  the  height 
of  the  temperature  and  the  virulence  of  the  organism  than  on  the  extent  of 
the  consolidation  or  on  any  especial  part  of  the  lung  being  affected,  such 
as  the  apex.  In  infancy  and  in  the  early  years  of  childhood,  in  place  of 
these  cerebral  symptoms  there  may  be  simply  an  apathetic  condition 
during  the  height  of  the  disease,  and  the  infant,  although  somewhat 
somnolent  and  restless,  often  shows  no  other  nervous  excitement. 

Cough. — Cough  is  a  common  symptom,  not  only  In.  the  beginning  of 
the  disease,  but  also  during  its  whole  course,  and  often  seems  to  be 
painful.  It  may,  however,  be  absent  for  several  days  in  the  beginning 
of  the  attack.  There  is  rarely  any  expectoration  before  the  seventh  or 
eighth  year,  and  hence  in  infants  and  young  children  we  rarely  see  the 
••  rusty''  sputum  so  characteristic  of  pneumo.coccus  pneumonia  in  adults. 
When  it  is  obtained  it  is  generally  rusty  and  tenacious,  and,  on  staming 
the  pneumococci  are  found  within  the  leucocytes  in  large  numbers. 

Blood. — The  blood  shows  a  marked  increase  in  the  leucocytes,  which 
begins  at  the  time  of  the  chill  and  may  rise  to  40,000  or  even  60,000,  or 
70,000.  In  cases  in  whicli  a  pseudocrisis  occurs  the  leucocytosis  persists, 
while,  in  certain  cases,  at  the  time  of  or  a  few  hours  before  the  true  crisis, 
the  white  blood-count  begins  to  diminish  and  reaches  its  normal  one  or 
two  days  after  the  temperature.  If  resolution  is  by  lysis,  the  reduction 
in  the  white  cells  is  gradual.  In  delayed  resolution,  the  leucocytosis  peri 
sists,  sometimes  for  weeks,  especially  if  abscess,  empyema,  or  gangrene 
develops  as  a  complication.  Cases  of  pneumonia  which  show  an  absence 
of  leucocytosis,  except  in  the  very  mildest  forms,  are  generally  considered 
of  very  unfavorable  prognosis.  A  high  and  increasing  white  blood-count 
is  of  value  only  as  an  aid  to  diagnosis,  and  is  no  guarantee  whatever  of  a 
favorable  issue. 

Pneumococci  can  usually  be  demonstrated  in  the  blood  in  pneumonia 

even  before  the  physical  signs  are  manifested.     Rosenow  found  them  in 

"i>l  per  cent,  in  a  series  of  175  cases.     Blood-cultures  are  therefore  often 

a  valuable  aid  to  diagnosis  in  obscure  cases.     Their  presence  in  the  blood 

does  not  necessarily  mean  a  bad  prognosis. 

Urine. — The  urine  shows  the  characteristics  of  a  febrile  urine, — high 
color,  high  specific  gravity,  and  increased  acidity,  with  a  slight  trace  of 
albumin  and  pure  hyaline  and  finely  granular  casts.  The  chlorides  are 
absent  or  greatly  reduced  at  the  height  of  the  fever  owing  to  the  large 
amount  ^vhich  is  deposited  in  the  consolidated  lung.  At  the  time  of  the 
crisis  there  is  often  a  marked  increase  in  the  amount  of  the  urine,  and  the 
chlorides  reappear.  The  alkaline  phosphates  are  also  greatly  diminished, 
and  reappear  with  beginning  resolution. 

*S7.7"//. — Herpes  of  the  nose,  lips,  genitals,  or  anus  occurs  not  uncom- 
monly in  association  with  pneumococcus  lobar  pneumonia.  Redness  of 
one  cheek  is  an  occasional  phenomenon,  but  is  not  necessarily  on  the 


DISEASES    OF    THE    BRONCHI    AND    LUNGS.  G70 

same  side  as  the  consolidation.  Cyanosis  is  seen  in  connection  with 
failing  circulation. 

Digestive  Organs. — The  tongue  is  white,  furred,  and  dry.  The  appe- 
tite fails,  diarrhoea  or  constipation  are  apt  to  appear,  and  meteorism  with 
considerable  distension  of  the  abdomen  is  sometimes  a  distressing  and 
grave  symptom.  The  spleen  is  usually  slightly  enlarged,  and  its  edge  is 
occasionally  palpable. 

Crisis. — The  time  Avhen  the  temperature  falls  and  the  crisis  takes 
place  varies.  It  may  occur  as  early  as  the  third  or  fourth  day,  but  is 
usually  between  the  fifth  and  the  eighth  day.  It  may,  however,  be  de- 
layed until  the  ninth  or  tenth  day,  and  in  rare  cases  still  longer.  This 
rapid  fall  in  the  temperature,  associated  with  the  initial  sudden  rise,  are; 
two  of  the  most  typical  and  valuable  symptoms  in  the  diagnosis  of  a 
pneumococcus  lobar  pneumonia.  When  the  temperature  falls  at  the 
crisis  of  the  disease  it  is  very  apt  to  become  subnormal,  and  to  remain  so. 
for  a  number  of  days.  Sometimes  after  the  temperature  has  fallen  to  the 
normal  it  may  rise  again,  but,  as  a  rule,  another  rise  of  temperature  points 
towards  the  involvement  of  some  fresh  area  of  the  lung  or  to  some  com- 
plication, such  as  pleurisy.  The  fall  of  temperature  at  the  time  of  the  crisis 
is  in  infants  less  frecfuently  accompanied  by  symptoms  of  great  prostration 
and  even  collapse,  but  it  is  nevertheless  important  to  watch  carefully  for 
the  crisis  and  to  be  prepared  to  combat  these  symptoms,  as  death  has 
occurred  at  this  time.  The  normal  height  of  the  temperature  in  acute 
lobar  pneumonia,  according  to  the  extensive  observations  of  Holt,  is 
from  40°  to  40.5°  C.  (104°  to  105°  F.).  In  children  over  three  years  of 
age  the  temperature  curve  resembles  tlie  adult  type  in  being  regular  and 
falling  by  crisis,  while  under  three  years  of  age  the  proportion  of  typical 
cases  is  much  less,  and  there  is  more  irregularity  in  the  course  of  the 
temperature,  which  falls  by  lysis  in  about  one-third  of  tlie  cases.  A  crisis 
is  less  common  in  pneumonias  of  infancy  than  in  adults.  The  younger  the 
individual  the  more  likelihood  there  is  of  a  wide  fluctuation  in  the  range 
of  the  temperature,  which  has  a  tendency  to  be  of  the  remittent  type  even 
in  uncomplicated  cases.  Morrill  and  others  have  shown  that  if  the, fall  in 
the  temperature  is  prolonged  beyond  the  tw^elfth  day  it  is  apt  to  subside 
by  lyses. 

Physical  Signs. — Inspection. — The  principal  features  observed  on  in- 
spection are  the  flushed  cheeks,  herpetic  vesicles  about  the  mouth  or 
nose,  short,  rapid,  and  superficial  respiration,  dilatation  of  the  alfe  nasi, 
and  sometimes  deficient  expansion  on  the  affected  side. 

Palpation. — In  typical  cases  the  tactile  fremitus  is  much  increased. 
If  the  air  is  excluded  from  the  bronchi  by  secretions  or  fibrinous  plugs, 
tactile  fremitus  is  not  obtained.  The  obstruction  may  sometimes  be -re- 
moved by  a  few  hard  coughs,  and  the  fremitus  then  returns. 

Percussion. — The  percussion-note  over  an  area  of  consolidation  var'^'s 
from  dulness  to  flatness  ;  it  may  be  tympanitic  in  equality  in  the  early  and 


680  PEDIATRICS. 

late  stages  of  the  disease.  In  the  pneumonias  of  infants  and  children 
dulness  is  especially  likely  to  be  absent,  and  if  the  base  of  the  lung  is 
consolidated,  a  tympanitic  quality  may  be  obtained  by  transmission  from 
a  distended  stomach  or  colon.  Wintrich  states  that  the  minimum  amount 
of  consolidation,  when  superficial,  which  will  produce  dulness  is  an  area 
five  centimetres  in  diameter  and  two  centimetres  deep. 

Auscultation. — The  respiration  in  infants  and  young  children  is  normally 
somewhat  harsh  or  broncho-vesicular  in  character,  and  should  not  be  mis- 
taken for  the  tubular  or  bronchial  breathing  which  is  characteristic  of  a 
consolidation.  If  the  tubes  are  filled  with  mucus  and  fibrin,  the  respira- 
tory sounds  may  be  much  diminished  and  even  absent,  closely  simulating 
a  pleural  exudation.  In  the  very  early  stag-es  the  breathing  may  be  feeble 
or  suppressed  over  the  affected  area,  and  very  fine  crackling  or  crepitant 
rales  may  be  heard  at  the  end  of  each  inspiration,  which  disappear  during 
consolidation  and  reappear  at  the  beginning  of  resolution.  Medium  and 
coarse  moist  rales  are  much  more  common  in  children  than  the  crepitant 
rales.  The  voice-sounds  are  intensified,  seem  near  to  the  ear  (bron- 
chophony), and  sometimes  have  a  nasal  quality  (egophony). 

Varieties. — Certain  variations  in  the  type  of  pneumococcus  lobar  pneu- 
monia occur,  and  have  been  designated  by  special  names.  In  apex  pneu- 
monia the  inflammation  is  limited  to  the  apex  of  the  lung.  In  massive 
pneumonia  the  exudation  fills  even  the  bronchi,  completely  consolidating 
the  lung,  and  giving  rise  to  physical  signs  Avhich  can  be  differentiated  from 
pleural  exudation  only  by  exploratory  aspiration.  In  migratory  or  creejjing 
pneumonia  one  lobe  after  another  is  involved.  Cerebral  pneumonias  are 
simply  those  forms  which  are  associated  with  severe  cerebral  symptoms. 
Some  writers  describe  an  abortive  Ujpje  of  pneumococcus  pneumonia  in 
which  the  signs  are  those  of  the  stage  of  congestion,  and  the  disease  runs 
a  course  of  from  twenty-four  to  forty-eight  hours.  We  have  not,  how- 
ever, seen  in  children  any  cases  in  which  the  evidence  Avas  sufficient  to 
justify  the  diagnosis. 

__  Central  pneumonia  is  a  type  of  the  disease  especially  common  in 
children.  The  clinical  symptoms  are  present,  but  the  physical  signs  are 
absent,  as  the  consolidation  is  deep-seated.  The  signs  may  not  come  to 
the  surface  for  many  days,  or  resolution  may  take  place  before  they 
appear. 

Delayed  Resolution. — The  crisis  in  lobar  pneunionia  is  not  always 
accompanied  by  a  resolution  of  the  consolidation  ;  the  local  signs  may 
persist,  and  disappear  only  in  the  course  of  several  weeks.  In  these 
cases  of  delayed  resolution  the  temperature  frequently  falls  by  lysis. 

The  following  case  illustrates  a  lobar  pneumonia  in  which  resolution 
was  delayed  for  thirty  days. 

A  girl,  four  years  old,  and  perfectly  well  and  strong,  was  suddenly  attacked  with 
vomiting,  pain  in  the  right  side,  and  cough  accompanied,  according  to  her  mother,  by 
a  reddish-brown  sputum.     Physical  examination  on  the  following  day  revealed  nothing 


DISEASES    OF    THK    BRONCHI    AND   LUNGS.  681 

abnormal  except  a  few  fine  moist  rales  at  the  base  of  the  right  lung  behind.  The 
pulse  was  170,  the  respirations  60,  and  the  temperature  39.4°  C.  (103°  F.).  On  the 
following  day  the  temperature  still  remained  raised,  and  there  was  dulness  on  percus- 
sion over  the  lower  right  lobe  behind,  with  bronchial  respiration.  On  the  following 
day  the  dulness  had  extended  over  the  whole  of  the  right  lung  in  front  and  behind. 
The  temperature  varied  from  38.8°  to  39.4°  C.  (102°  to  103°  F.),  the  pulse  from  150 
to  160,  and  the  respirations  from  60  to  60.  These  symptoms  continued  until  the  eighth 
day  from  the  onset  of  the  attack,  when  the  temperature  was  found  to  be  38.4°  C. 
(101.2°  F.),  the  respirations  48,  and  the  pulse  160.  During  the  next  nine  days  the 
temperature,  pulse,  and  respirations  remained  the  same,  and  there  was  no  change  in 
the  physical  signs  of  the  lung,  except  that  in  addition  to  the  dulness  and  bronchial  respi- 
ration a  number  of  fine  moist  rales  Avei'e  heard  in  the  back  and  in  the  axillary  regions. 
During  the  next  week  no  change  took  place  in  the  temperature,  pulse,  respiration,  or 
physical  signs.  Some  days  later  the  temperature  fell  to  the  normal,  the  respirations  to 
36,  the  pulse  to  135,  the  dulness  began  to  disappear,  and  the  numerous  coarse  and 
fine  moist  rales  of  resolution  appeared.  Resolution  took  place  rapidly,  and  a  week 
later,  thirty  days  from  the  onset  of  the  attack,  the  lung  appeared  to  be  in  a  perfectly 
normal  condition.  From  that  time  the  child  gained  rapidly  in  strength  and  weight  and 
recovered  completely. 

The  following  cases  illustrate  tlie  type  of  a  central  pneumonia.  They 
showed  the  clinical  symptoms  of  a  lobar  pneumonia,  quick  respirations, 
rapid  pulse,  dilatation  of  the  alae  nasi,  apathy,  delirium,  and  vomiting,  but 
the  physical  signs  did  not  appear  in  the  lung  for  a  number  of  days.  The 
w^hole  course  of  the  disease  and  the  physical  signs  were  so  similar  in  both 
instances  that  one  description  will  suffice  for  both. 

There  were  two  boys,  brothers,  the  older  boy  being  three  years  and  the  younger 
sixteen  months  old.  The  older  boy  was  attacked  on  November  19,  and  the  younger 
one  on  November  20,  with  continuous  vomiting,  which  lasted  without  much  inter- 
mission until  November  26.  In  addition  to  the  vomiting  the  temperature  rose  in  the 
first  twenty-four  hours  to  40.5°  C.  (105°  F.),  and  until  November  26  varied  from  40° 
to  40.6°  C.  (104°  to  105°  F.).  The  respirations  varied  from  40  to  50,  and  the  pulse 
from  150  to  160.  Both  children  soon  became  unconscious,  were  very  restless,  rolled 
their  heads  continuously,  and  showed  contracted  pupils.  On  November  26  the  tem- 
perature fell  to  39.4°  C.  (103°  F.),  and  during  the  next  two  days  varied  from  39.4° 
to  40°  C.  (103°  to  104°  F.).  On  November  27  a  small  area  of  flatness  with  bronchial 
respiration  was  detected  in  the  older  boy  over  the  left  upper  lobe  in  front,  and  on  the  fol- 
lowing day  in  the  younger  boy  over  the  left  lower  lobe  behind.  After  the  first  few  days 
there  was  slight  cough  in  both  cases,  with  movement  of  the  altB  nasi.  On  November  30  - 
the  temperature  in  both  children  rose  to  40.6°  C.  (106°  F.),  and  until  December  2  it 
varied  from  40°  to  40.6°  C.  (104°  to  105°  F.).  On  the  evening  of  December  2  the  tem- 
perature in  the  older  boy  suddenly  fell  from  40.5°  C.  (105°  F.)  to  36.5°  C.  (96°  F.). 
The  child  became  cold,  the  pulse  became  feeble,  and  the  respiration  could  scarcely  be 
detected.  The  application  of  a  hot  pack  and  an  enema  of  hot  brandy-and-water 
rapidly  revived  the  child.  The  same  fall  of  temperature  occurred  in  the  other  boy  on 
the  following  morning.  In  both  children  signs  of  resolution  were  detected  before  the 
temperature  fell,  the  lungs  in  both  cases  rapidly  became  normal,  and  after  a  short 
convalescence  the  children  recovered  completely. 

In  some  cases  lobar  pneumonia  may  attack  both  lungs.  Again,  after 
the  disease  has  run  its  course  and  the  temperature  has  fallen  to  nor- 


(^82  PEDIATRICS. 

mal,  a  fresh  portion  of  the  lung  may  be  involved  and  the  temperature 
may  rise  again.  In  rare  instances  in  otherwise  typical  cases  of  lobar 
pneumonia  we  have  been  unable  to  detect  any  rales  over  the  area  of  solidi- 
fication throughout  the  whole  course  of  the  disease. 

Complications  and  Sequels. — The  complications  of  pneumococcus  lobar 
pneumonia  are  not  numerous. 

Pleurisy  always  occurs  if  the  inflammation  is  superficial.  It  may  be 
dry,  fibrinous,  sero-fibrinous,  or  purulent  (empyema).  The  presence  of 
exudation  renders  the  diagnosis  much  more  difficult,  and  aspiration  is 
usually  necessary  to  determine  the  condition. 

Pcrkardiiis  may  occur,  and  is  more  common  in  children  than  in 
adults.  It  is  frequently  associated  with  pericardial  exudation,  which  is 
either  serous  or  purulent.  Recovery  may  occur  even  in  a  purulent  peri- 
carditis (Murchison). 

Oiitis  media  is  not  an  infrecfuent  complication  in  children.  In  Morse's 
series  it  was  the  most  frequent  complication,  occurring  in  18  per  cent,  of 
the  cases,  whereas  empyema  developed  in  only  8  per  cent,  in  the  same 
series.  Often  the  only  suggestion  of  its  presence  is  a  sudden  rise  in  the 
temperature.  Rigidity  of  the  neck,  simulating  meningitis,  is  in  many  in- 
stances due  to  otitis  media. 

Gangrene  of  the  lungs  is  of  very  rare  occurrence,  but  may  be  the 
terminal  process  of  a  delayed  resolution.  In  the  same  way  an  abscess  of 
the  lung  may  develop  ;  it  may  perforate  into  the  pleural  cavity  and  pro- 
duce an  empyema,  or  into  a  bronchus  and  the  pus  be  expectorated. 

Other  rare  complications  due  to  the  pneumococcus  are  meningitis, 
endocarditis,  and  peritonitis. 

Diagnosis. — The  diagnosis  of  pneumococcus  lobar  pneumonia,  when 
the  typical  temperature  and  the  characteristic  physical  signs  are  present, 
is  not  difficult,  but  there  are  a  number  of  atypical  cases  in  which  a  doubt 
might  easily  arise  for  a  number  of  days  alter  the  invasion  of  the  disease. 
When  a  specimen  of  the  sputum  can  be  obtained,  the  character  of  the 
-infection  can  often  be  determined  at  once,  even  when  the  physical  signs 
are  not  distinctive,  by  a  bacteriological  examination  in  reference  to  the 
presence  of  the  pneumococcus  in  large  numbers,  alone  or  associated  with 
other  organisms,  within  the  leucocytes. 

From  Pleural  Exudation. — An  early  diagnosis  from  a  pleural  exudation 
is  at  times  impossible,  and  is  always  quite  difficult  in  the  early  stages 
before  the  characteristic  signs  of  consolidation  have  been  established.  In 
both  diseases  dulness  or  flatness  over  a  limited  area,  and  bronchial  respi- 
ration without  any  especial  difference  in  the  tactile  fremitus  and  vocal 
resonance,  and  without  evidence  of  a  friction-rub  or  of  rales,  may  make 
the  t\vo  diseases  simulate  each  other  closely  and  compel  us  to  wait  for 
further  developments  before  determining  the  differential  diagnosis.  This 
similarity  in  the  signs  of  fluid  and  consolidation  is  especially  characteristic 
in  children.    In  typical  cases  of  pleural  exudation  the  absence  or  marked 


DISEASES    OF    THE    BRONCHI    A.\D    LUNGS.  683 

diminution  of  tactile  fremitus  and  vocal  resonance,  the  shifting  character 
of  the  area  of  dulness  on  change  of  position,  the  diminished  intensity  of 
the  respiratory  sounds,  bulging  of  the  intercostal  spaces,  and  displace- 
ment of  the  heart,  and  of  the  liver  in  exudations  on  the  right  side,  are 
signs  which  render  definite  the  diagnosis  from  a  consolidated  lung.  In 
atypical  cases,  liowever,  the  signs  may  so  closely  resemble  those  of  pneu- 
monia that  the  diagnosis  can  only  be  made  by  exploratory  puncture. 

From  Tuberculosis  of  the  Lung. — In  tubercular  disease  of  the  lung  the 
differential  diagnosis  is  usually  not  difficult,  except  in  young  infants,  in 
whom  tlie  tubercular  process  with  its  corresponding  symptoms  may  in 
rare  cases  simulate  lobar  pneumonia.  The  onset  of  the  symptoms,  the 
course  of  the  disease,  and  the  examination  of  the  sputum,  will,  in  nearly 
all  uncomplicated  cases,  make  the  diagnosis  clear. 

From  Broncho-Pneumonia. — The  disease  from  which  a  differential 
diagnosis  should  especially  be  made  is  broncho-pneumonia.  Lobar  pneu- 
monia and  secondary  broncho-pneumonia  are  so  distinct,  however,  in 
their  previous  history,  initial  stage,  course,  and  duration  that,  if  care  be 
taken  to  note  closely  all  these  stages  of  the  two  diseases  and  to  arrive  at 
a  diagnosis  from  the  evidence  given  by  all  the  stages  and  not  by  any  one 
stage,  the  diagnosis  can,  except  in  the  very  early  days  of  the  disease, 
usually  be  determined.  Lobar  pneumonia,  in  contradistinction  to  the 
secondary  form  of  broncho-pneumonia,  is  a  primary  disease,  characterized 
by  a  sudden  onset  and  a  regular  temperature,  which  rises  abruptly.  This 
is  accompanied  by  a  corresponding  rapidity  of  the  pulse  and  respirations, 
dulness  on  percussion  usually  involving  and  limited  to  one  lobe  or  one 
lung,  with  increased  vocal  fremitus  and  resonance,  and  bronchial  respira- 
tion over  the  dull  area.  This  is  followed  by  a  fall  of  temperature  and  by 
a  rapid  resolution.  The  duration  is  short  and  definite.  Broncho-pneu- 
monia, on  the  other  hand,  is  usually  secondary  to  a  preceding  bronchitis, 
occurring  either  alone  or  in  the  course  of  some  other  disease.  It  is  charac- 
terized by  a  slow  and  insidious  onset,  except  when  it  occurs  in  the  course 
of  measles ;  it  has  an  irregular  temperature,  the  rise  usually  not  being  so 
sudden  or  so  high  as  in  lobar  pneumonia,  and  the  respirations  and  pulse 
slowly  increase  with  the  temperature.  There  is  often  an  absence  of 
change  in  percussion,  the  dulness  if  present  showing  itself  in  small 
patches  and  commonly  in  both  lungs.  There  is  also  often  an  absence  of 
marked  vocal  fremitus  or  vocal  resonance,  and  of  bronchial  respiration, 
except  where  the  patches  of  dulness  are  pronounced.  Moist  rales  of  all 
sizes  may  be  heard  in  circumscribed  areas  throughout  both  lungs.  The 
temperature  is  usually  of  a  remittent  type,  and  this  condition  lasts  for  weeks 
rather  than  days,  the  duration  often  being  prolonged.  If  these  pictures 
of  the  two  diseases  are  borne  in  mind,  an  error  in  the  differential  diag- 
nosis will  seldom  be  made.  In  the  doubtful  cases,  in  which  the  character- 
istic course  of  either  disease  is  absent,  it  will  usually  be  found  that  we 
are  dealing  with  a  case  of  broncho-pneumonia,  which  is  an  exceedingly 


(J84  PEDIATRICS. 

variable  disease,  rather  than  with  lobar  pneumonia,  in  which  some  of  the 
characteristic  features  of  the  disease  are  almost  invariaJDly  present. 

The  piimary  forms  of  broncho-pneumonia,  as  described  on  page  691, 
are  very  difficult  to  differentiate  ii"om  acute  pneumococcus  pneumonia, 
especially  when  the  consolidation  is  central,  and  in  these  cases  we  are 
generally  obliged  to  wait  until  the  physical  signs  have  become  distinctive. 

Another  condition  in  which  the  diagnosis  is  veiy  obscure  occurs  in 
those  cases  of  broncho-pneumonia  in  which  the  areas  of  consolidation 
have,  by  confluence,  involved  the  Avhole  or  a  greater  part  of  a  lobe. 

From  Meningitis. — Pneumonia  in  children  may  be  entirely  masked  by 
the  intensity  of  the  cerebral  symptoms.  In  making  the  diagnosis  between 
pneumonia  and  meningitis  it  is  of  much  aid  to  remember  that  the  slow 
intermittent  pulse,  slow  uTegular  respiration,  and  moderate  temperature 
of  meningitis  are  uncommon  in  lobar  pneumonia,  in  which  in  most  cases 
the  pulse  is  rapid  and  regular,  th-e  respu'ations  rapid,  and  the  temperature 
high.  It  is  not  uncommon,  however,  to  find  irregularities  and  intermis- 
sions in  the  rapid  pulse  of  pneumonia.  The  younger  the  individual  the 
more  likely  are  the  symptoms  of  tubercular  meningitis  to  be  replaced  by 
those  of  the  non-tubercular  form  of  the  disease,  which  may  often  simu- 
late closely  the  symptoms  of  pneumonia.  The  convulsions  which  occur 
in  pneumonia  do  not  differ  from  those  which  occur  in  meningitis,  or,  m 
fact,  in  any  other  acute  disease.  A  careful  physical  examination  should 
be  made  at  every  visit,  once  or  twice  a  day  if  possible,  as  in  this  way  the 
masked  symptoms  of  a  pneumonia  may  at  times  be  detected  where  they 
would  be  overlooked  if  only  an  occasional  exammation  were  made. 
After  the  first  four  or  five  days,  as  a  rule,  the  differential  diagnosis  be- 
tween cerebral  disease  and  pneumonia  is  not  difficult.  Lumbar  puncture 
is  of  much  value  in  the  diagnosis  of  meningitis  in  these  cases. 

From  Lifluenza. — The  presence  of  a  aa  ell-marked  leucocytosis  is  of 
much  service  in  excluding  influenza,  but  the  possibility  of  an  influenza 
pneumonia  must  be  borne  in  mind.  In  the  latter  case,  if  leucocytosis  is 
present  at  all.  it  is  rarely  high,  and  the  examination  of  the  sputum,  the 
course  of  the  disease,  and  the  character  of  the  physical  signs  generally 
make  the  diagnosis  clear. 

From  Malaria. — The  onset  of  malaria  may  closely  resemble  that  of 
lobar  pneumonia,  but  its  subsequent  course  is  essentially  different.  A 
chill  with  a  sharp  rise  in  the  temperature,  associated  with  a  marked  leu- 
cocytosis, is  rarely,  if  ever,  due  to  malaria. 

Prognosis. — The  prognosis  of  pneumococcus  lobar  pneumonia  in  in- 
fants is  usually  said  to  be  very  favorable,  but  Morse's  recent  analy- 
sis of  118  cases  showed  a  mortahty  of  31.9  per  cent,  in  the  first  year, 
17,9  in  the  second  year,  or  an  average  of  22.8  per  cent,  in  the  first  two 
years  of  life..  The  average  duration  in  the  uncomplicated  fatal  cases  in 
this  series  was  12.8  days,  compared  with  8.1  days  in  those  which  re- 
covered.    The  mortality  was  lowest  where  the  temperature  did  not  rise 


DISEASES    OF    THE    BRONCHI    AXD    LUNGS.  685 

above  39.4°  C.  (103°  F.) ;  it  was  highest  in  the  cases  which  went 
over  41.1°  C.  (106°  F.).  The  degree  of  fever  between  39.4°  C.  (103° 
F.)  and  44.1°  C.  (106°  F.)  had  no  effect  upon  the  mortality.  No  case 
died  in  which  the  pulse  was  under  140  or  the  respiration  below  55. 
The  mortality  in  children  in  early  childhood  is  very  much  lower  than 
in  infancy  or  adult  life,  in  some  large  series  running  as  low  as  3  per 
cent.,  in  striking  contrast  to  the  high  death  rate  in  the  first  and  second 
year.  The  convulsions  which  occur  in  the  initial  stage  of  the  disease 
in  infants  are  commonly  not  of  grave  import.  Occurring  late  in  the 
disease  they  make  the  prognosis  very  unfavorable.  When  delirium  oc- 
curs, although  it  may  be  severe,  it  does  not  render  the  prognosis  especially 
bad.  The  fulminant  type  of  the  disease  which  sometimes  occurs  is  a 
very  fatal  form. 

Treatment. — As  lobar  pneumonia  is  a  self-limited  disease  of  short 
duration,  the  children  are  not  apt  to  die  of  exhaustion,  and,  as  a  rule, 
only  an  expectant  treatment  is  called  for.  It  is  doubtful  if  any  drug  treat- 
ment can  ever  abort  the  disease.  P».are  cases  in  which  the  disease  appears 
to  abort  occur  when  the  treatment  is  only  expectant. 

Xursing  and  General  Hygiene. — The  child  should  be  placed  in  a  room 
of  an  equable  temperature  of  20°  or  21.1°  C.  (68°  or  70°  F.).  An  abun- 
dance of  fresh  air  should  be  supplied  from  open  windows,  the  temper- 
ature of  the  room  being  maintained  by  an  open  wood-fire.  Milk  should 
be  given  every  two  hours.  There  is  no  necessity  for  making  any  external 
applications  to  the  chest.  The  use  of  poultices  is  to  be  deprecated,  and 
in  our  experience  is  usually  without  benefit  except  in  certain  instances  for 
the  relief  of  pain,  in  which  a  cotton  jacket  is  sometimes  useful.  The 
nursing  is  of  especial  importance,  and  close  watchfulness,  especially  at  the 
time  when  the  crisis  is  expected  to  take  place.  At  this  time  the  temper- 
ature in  infants  and  young  children  may  fall  with  such  rapidity  to  several 
degrees  below  the  normal  point  that  collapse  occasionally  takes  place ; 
the  skin  is  cold  and  moist,  and  sometimes  the  child  becomes  unconscious. 
Under  these  circumstances  the  pulse  is  feeble  and  intermittent,  and  in 
some  cases  death  may  occur  unless  active  measures  are  taken  to  bring 
about  a  reaction.  The  nurse  should  therefore  be  warned,  as  the  time 
of  the  expected  crisis  approaches,  to  watch  the  child  both  night  and  day, 
and  to  have  remedies  ready  to  be  used  in  case  serious  symptoms  should 
arise. 

These  remedies  should  be  the  external  application  of  heat  by  means 
of  the  hot  pack,  and  the  administration  of  brandy  by  the  mouth  if  the 
child  can  swallow ;  otherwise  by  rectal  injection.  We  have  known  of 
a  case  in  which  a  child  died  in  the  collapse  following  the  crisis  of  a  lobar 
pneumonia.  It  is  often  not  necessary  to  use  any  remedy  whatever,  and 
it  is  safer  to  wait  until  there  are  indications  for  the  use  of  drugs.  There 
is  no  remedy  which  will  shorten  the  course  of  the  disease.  Rest  and 
sleep  is  of  first  importance.  ,  The  medication  and  feeding  should  be  so 


(;,S(^  rKDlATHK'S. 

regulated  as  to  allow  peiiods  of  three  or  four  hours,  in  which  the  child 
may  remain  undisturbed.  In  young  infants  food  must  be  given  more 
frequently  and  the  periods  are  therefore  shorter.  Some  mild  hypnotic, 
such  as  bromide  of  soda,  trional,  or  somnos,  may  be  given  to  produce 
sleep  when  it  does  not  occur  naturally.  Cardiac  weakness,  hyperpyrexia, 
pain,  and  toxaemia  are  tlio  fmir  indications  wliich  require  special  sympto- 
matic treatment. 

Cardiac  Weakness. — The  condition  of  the  chx-ulation  should  be  care- 
fully watched.  When  the  disease  occurs  in  very  young  infants  it  is  safer 
to  administer  stimulants  from  the  beginning.  Brandy,  or  whiskey,  and 
strychnine  are  the  most  serviceable  drugs  for  a  cardiac  stimulant.  The 
brandy  should  be  adapted  to  the  age  of  the  child  as  given  on  page  456, 
and  the  strychnine  as  stated  on  page  470.  The  limits  of  administration 
will  depend  upon  the  way  in  which  the  heart  responds  to  the  stimulant. 
In  separate  cases  the  stimulant  should  be  given  subcutaneously  for  greater 
efficiency.  Inhalation  of  oxygen  often  gives  great  relief  when  there  is 
cyanosis  and  marked  dyspnoea.  Small  doses  of  nitroglycerin  are  also 
used  when  the  cyanosis  is  associated  with  a  full,  high-tension  pulse.  Aro- 
matic spirits  of  ammonia  may  also  be  used  to  supplement  the  alcohohc 
stimulation. 

Hyperpyrexia. — Although  at  times  a  high  temperature  does  not  neces- 
sarily indicate  danger,  since  a  temperature  of  from  40°  to  40.5°  C.  (104° 
to  105°  F.)  is  part  of  the  regular  course  of  the  disease,  yet  if  the  tem- 
perature rises  above  this  point  it  is  well  to  reduce  it  by  means  of  bath- 
ing and  to  give  alcoholic  stimulants.  It  must,  however,  be  understood 
that  it  is  not  the  height  of  the  temperature  so  much  as  the  intensity 
of  the  nervous  symptoms  which  determines  the  indication  for  antipyretic 
treatment. 

Pain  and  Cough. — Pain  and  cough  are  often  distressing  symptoms,  and 
may  at  times  require  small  doses  of  paregoric,  adapted  to  the  age  of  the 
child.  From  one  to  three  months,  0.06  to  0.12  c.c.  (1  to  2  minims)  may  be 
^iven ;  at  one  year,  0.3  to  0.6  c.c.  (5  to  10  minims) :  and  at  five  years,  1.8 
to  2.4  c.c.  (30  to  40  minims). 

Codeine  sulphate  may  also  be  used  with  advantage.  The  application 
of  ice-poultices  is  indicated  but  only  for  short  periods. 

Toxcemia. — Although  extensive  investigations  have  been  made  in  regard 
to  the  serum  therapy  of  pneumococcus  lobar  pneumonia,  the  efficiency 
and  expediency  of  the  treatment  is  still  in  doubt.  The  only  means  we 
possess  of  combating  the  toxines  is  by  reduction  of  the  fever  and  by 
general  supportive  treatment. 

Convalescence.  —  During  convalescence  the  child  should  be  carefully 
protected,  for  some  months,  from  atmospheric  changes,  cold,  and  dampness 
and  its  food  and  habits  should  be  carefully  regulated. 

Lobar  pneumonia  may  occur  in  the  earliest  days  of  life.  We  have  met 
with  a  case  which  on  the  third  day  of  its  life  developed  a  lobar  pneu- 


DISEASES    OF    THE    BRONCHI    AND    LUNGS.  0*87 

monia  and  died  in  twenty-four  hours.     The  autopsy  showed  the  char- 
acteristic hepatization  of  lobar  pneumonia. 

The  following  case  illustrates  lobar  pneumonia  : 


A  boy,  eight  years  old,  entered  the  hospital  on  the  fourth  day  of  an  attack  of  lobar 
pneumonia.     The  attack  began  with  vomiting  and  cough,  but  no  pain,  expectoration. 


or  chill. 


CHAET  28. 


An  examination  showed  the  right  lung  to  be  normal.  On  the  left  side  of 
the  chest  an  area  corresponding  to  the  lower  lobe  in  the  back 
was  found  to  show  dulness  on  percussion,  bronchial  respira- 
tion, and  many  fine  moist  rales.  Nothing  else  abnormal  was 
detected.  The  child  was  very  restless,  but  on  the  following 
day,  the  fifth  from  the  onset  of  the  disease,  the  temperature 
fell  by  crisis  to  the  normal  point.  Chart  28  shows  the  typical 
temperature,  pulse,  and  respiration  of  a  case  of  lobar  pneu- 
monia. 

After  the  crisis  the  child  improved  rapidly,  and  the 
physical  signs  disappeared  in  ten  days. 

A  girl,  two  and  a  half  years  old,  entered  the  hospital  on 
the  third  day  of  an  attack  of  lobar  pneumonia.  Chart  29 
shows  one  of  the  variations  in  the  crisis  which  is  quite  fre- 
quently met  with  in  young  children.  The  temperature  in 
this  case  reached  the  normal  on  the  tenth  day. 

In  this  case  the  consolidated  portion  of  the  lung  was  the 
left  lower  lobe.  The  resolution  was  rapid  and  convalescence 
normal. 

A  girl  (Fig.  143),  eight  years  old,  had  pertussis  when  she 

CHAET  29. 


hay  a  of  Disease 

F. 

4 

5 

6 

7 

8 

c. 

107° 
106° 
105° 
104° 

|103 

102 

101° 

100° 

99° 

"qs 

07° 
66° 
95° 

ME 

M£ 

ME 

ME 

M  E 

41  6° 

41  1° 

'40.5' 

40.0* 

39.4' 

38.8° 

38.3° 

37.7* 

37.2° 
37.0° 
36.6° 

36.1° 

35.6° 

35.0° 

/ 

n 

/ 

Si 

^ 

150 
140 
130 

120 
110 
100 
90 
80 
70 
60 

s. 

\ 

\^ 

\ 

N 

50 
45 
40 
35 
30 
25 
20 
15 
JO 

.2 
1 

/ 



\^ 

U- 

1 — 

^ 

1 

_j 

Lobar  pneumonia.  Male, 
S  years  old.  Crisis  on 
fifth  dav  of  disease. 


Days  of  Disease.                   |1 

V. 

3 

4 

5 

6 

7 

8 

9 

10 

c. 

407° 
106° 

ids' 

104° 
i03 
102° 
101° 
100° 
99 
98 
67° 
96 
95° 

HE 

ME 

ME 

ME 

ME 

ME 

MB 

ME 

4i.e° 

41.1" 
40.5* 
40.0° 
39.4° 
38.8° 
38.3° 
37.7° 
37.2° 
37.0° 
36.6° 

36.1'^ 
35.5° 
35.0°' 

y 

/ 

/ 

/ 

/ 

—^ 

\ 

u 

u 

Lobar  pneumonia.    Irregular  crisis  on  eighth 
day.    Female,  2>g  years  old. 


was  fourteen  months  old,  scarlet  fever  when  she  was  five  years  old,  and  measles  when 
she  was  six  years  old.  Five  days  before  entrance  she  lost  her  appetite,  was  very 
feverish,  and  was  attacked  with  acute  pain  referred  to  the  left  side  of  the  epigastrium 
and  the  lower  part  of  the  left  axillary  region.  This  was  accompanied  with  a  hacking 
paroxysmal  cough,  with  no  expectoration.  She  became  delirious,  vomited  occasionally, 
and  was  very  weak.  Her  tongue  was  heavily  coated,  the  alae  nasi  moved  with  respira- 
tion, her  face  was  deeply  flushed,  and  the  dyspnoea  was  so  severe  that  she  had  to  be 
propped  up  on  pillows. 

Her  respirations  were  45,  difficuU  and  painful,  her  pulse  120,  and  her  tempera- 


688 


PEDIATRICS. 

Fig.    14?, 


Lobar  pneumonia.  Female.  8  years  old.  The  part  of  the  lunar  involverl  hy  the  pneumonic,  process 
is  shown  by  black  lines,  and  the  area  of  diminished  resonance  and  the  fine  rales  are  marked  by  black 
spots. 


Fig.   144. 


Lobar  pneumonia.    Three  invasions.    Malc\  ''  vears  old. 


DISEASES   OF   THE   BRONCHI   AND    LUXGr5. 


689 


CHAET  30. 


ture  39.5°  C.  (103.2°  F.).  A  physical  examination  detected  nothing  abnormal  in  the 
front  of  the  chest  or  in  the  right  back.  There  was  flatness  in  the  left  back,  beginning 
at  the  fifth  rib  and  extending  to  the  base  of  the  lung  and  into  the  axillary  region. 
Over  this  area  there  was  increased  vocal  fremitus  and  bronchial  respiration,  and  a  few 
moist  rales.  Just  above  the  upper  border  of  the  area  of  flatness  there  were  diminished 
resonance  and  a  number  of  fine  rales.  Although  the  examination  was  made  on  the 
fifth  day  of  the  disease,  the  physical  signs  showed  that  resolution  had  begun  and  that 
the  crisis  miglit  be  expected  at  any  time. 

On  the  following  day  the  temperature  fell  to  37.7°  C.  (100°  F.j  in  the  morning, 
but  rose  again  in  the  evening  to  39.1°  C.  (102.5°  F.).  On  the  following  day,  the 
seventh  day  from  the  beginning  of  the  attack, 
the  temperature  fell  to  37.2°  C.  (99°  F.), 
and  then  varied  from  37.7°  C.  (100°  F.)  to 
37.2°  C.  (99°  F.)  until  the  eleventh  day. 
when  it  became  normal.  The  pulse  and 
respirations  declined  synchronously  with  the 
temperature. 

This  case  illustrates  the  fact  that  the 
physical  signs  of  resolution  may  sometimes 
appear  before  the  temperature  falls  and  the 
crisis  comes  ;  also  that  at  the  time  of  the 
crisis  the  temperature  may  fall,  then  rise 
again  for  from  twelve  to  twenty-four  hours, 
and  then  fall  to  the  normal.  The  child  re- 
covered completely. 

Another  child,  a  boy  (Fig.  144),  six 
years  old,  was  taken  sick  four  days  before 
entering  the  hospital. 

On  entering  the  hospital  his  pulse  was 
128,  his  respirations  60,  and  his  temperature 
39.8°  C.  (103.8°  F.)  A  physical  examina- 
tion showed  that  there  was  flatness  over  the 
entire  upper  lobe  of  the  right  lung  ;  over 
this  area  there  were  bronchial  respiration, 
increased  vocal  resonance,  and  an  occa- 
sional high-pitched  rale.  The  left  lung  was 
normal.  The  lower  border  of  the  dulness 
produced  by  the  consolidated  upper  lobe  has 
been  marked  by  a  black  line  extending  from 
the  sternum  just  above  the  right  mamma 
and  around  into  the  axillary  region.  On 
the  morning  of  the  sixth  day  from  the  be- 
ginning of  the  attack  the  temperature  fell 
to  37.7°  C.  (100°  F.).  but  rose  again  in  the 
evening  to  40.5°  C.  (105°  F.)  and  a  physical 
examination  then  showed  that  the  middle 
lobe  of  the  right  lung  was  involved  in  front, 
below  the  one  just  described. 


Days  of  Disease. 

107° 
106 
105 
104° 
103° 
102= 
101 
100 

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96 

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c. 

ME 

ME 

ME 

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ME 

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ME  UE 

ME 

ME 

ME 

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41.6° 
41  1° 
40.5° 
40.0° 

aeV 

3s.a° 

38.3° 
37  7° 
37.2° 

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i 

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■'— ■ 

36.6° 
36.1* 
35.5° 
35.0° 

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ISO 
140 
130 

120 

iio| 

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90 

sol 
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70 

60j 

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L 





Lobar  pneumonia  of  the  migratory  type.    Male 
6  years  old. 


as  indicated  by  the  second  black  line 
The  temperature  during  the  next  two  days  remained 
between  39.4°  and  40°  C.  (103°  and  105°  F.),  but  on  the  following  day,  the  ninth  from 
the  onset  of  the  disease,  the  temperature  suddenly  fell  to  37.6°  C.  (99.7°  F.)  in  the 
evening,  but  rose  the  next  morning  to  39.3°  C.  (102.8°  F.),  and  in  the  evening  was 
39.8°  C.  (103.8°  F.).  A  physical  examination  then  showed  that  the  whole  of  the 
lower  lobe  was  involved,  as  indicated  by  the  third  black  line.      On  the  following  day 

44 


690  PEDIATRICS. 

the  upper  lobe  began  to  show  evidence  of  resolution,  and  the  temperature  fell  h^ 
38.3°  C.  (1U1°  F.).  Two  days  later  the  temperature  began  to  fall  by  lysis,  the  physical 
signs  of  the  upper  and  middle  lobes  entirely  disappeared,  and  the  temperature  reached 
the  normal  point  on  the  lourteenth  day  from  the  time  of  the  onset.  On  the  seven- 
teenth day  from  the  time  of  the  onset  the  lower  lobe  was  also  found  lu  be  in  a  normid 
condition,  and  from  that  time  convalescence  was  uninterrupted. 

Chart  30  shows  the  temperature,  pulse,  and  respirations  in  this  case  from  11h' fifth 
to  the  seventeenth  day  of  the  disease. 

In  some  rare  cases  the  infection  in  lobar  pneumonia  is  so  ovenvlielming 
tliat  a  rapidly  fatal  issue  may  occur. 

We  have  seen  a  little  girl,  nineteen  months  old,  who  had  been  having  so  mild  an 
attack  of  diarrhoea  that  she  was  playing  about  out  of  doors,  suddenly  attacked  in  tlie 
afternoon  with  convulsions  and  a  temperature  of  40.5°  C.  (105°  F.).  The  convulsions 
continued  during  the  night,  and  she  soon  became  comatose.  On  the  following  day 
the  temperature  still  remained  at  40.5°  C.  (105°  F.).  the  respiiatimis  were  much 
accelerated,  and  the  pulse  was  about  120.  An  area  of  absolute  dulness  over  the  left 
lower  lobe  behind,  with  ])ronchial  respiration  and  increased  vocal  resonance  and  fremitus, 
rapidly  developed.      The  cliild  did  not  respond  to  treatment,  and  died  in  the  evening. 

LOBAR  PNEUMOISnA  DUE  TO  OTHER  ORGANISMS. 

It  occasionally  happens  in  a  very  small  percenta,i;e  of  cases,  as  lias 
already  been  stated,  that  in  an  acute  infection  of  the  lung  an  entire  lobe, 
or  the  greater  part  of  a  lobe,  may  become  consolidated  in  conditions 
other  than  that  of  a  pneumococcus  lobar  pneumonia.  This  fact  and  the 
custom  of  applying  the  term  "  lobar  pneumonia"  to  intlammations  of  the 
lung  produced  by  the  pneumococcus  have  led  to  more  or  less  confusion  in 
the  description  of  the  etiology  and  classification  of  the  various  forms  of 
pneumonia.  Reference  has  already  been  made  on  page  426  to  the  rare 
cases  of  total  consolidation  of  a  lobe  occurring  as  a  result  of  an  infection 
of  the  lung  by  the  diplococcus  intracellularis  secondary  to  an  epidemic 
cerebrospinal  meningitis.  Other  cases  occur  in  which  tlie  pneumococcus 
is  found  in  a  mixed  infection,  associated  with  some  form  of  pus-producing 
-organism,  sucli  as  the  staphylococcus  pyogenes  aureus  and  the  strepto- 
coccus pyogenes,  or  with  the  bacillus  of  influenza,  the  bacillus  of  Fried- 
lander,  the  Klebs-Loeffler  bacillus,  and  rarely  the  typhoid  bacillus.  More- 
over, there  is  the  class  of  cases  in  which  the  etiology  and  pathology  are 
those  of  a  pure  broncho-pneumonia,  in  the  course  of  which  all  the  lobules 
of  the  affected  lung  have  become  confluent,  giving  rise  to  the  gross  ap- 
pearances and  physical  signs  of  a  lobar  consolidation.  Whether  a  lobar 
pneumonia  with  the  gross  and  microscopic  appearances  of  a  typical 
pneumoccoccus  lobar  pneumonia  can  ever  be  due  to  a  single  organism 
other  than  the  pneumococcus  is  a  question  which  the  present  state  of  our 
knowledge  of  the  etiology  and  pathology  of  the  disease  does  not  warrant 
us  in  answering  definitely. 

Lobar  pneumonias  which  are  caused  in  the  manner  just  outlined 
often  differ  in  their  clinical  symptoms  and  course  from  those  f)f  a  pneu- 


DISEASES    OF   THE   BRO.XCHI  AND    LUXGS.  691 

mococcus  lobar  pneumonia.  They  are  much  more  apt  to  be  subacute  at 
"their  onset,  secondary  to  some  other  infection,  and  to  run  a  more  irregular 
course,  resembling  closely  that  of  a  broncho-pneumonia.  The  bacterio- 
logical examination  of  the  sputum  is  of  the  greatest  aid  in  these  cases,  and 
may  often,  in  connection  with  the  clinical  symptoms  and  physical  signs  in 
the  early  stages  of  the  disease,  enable  us  to  make  a  differential  diagnosis. 
Treatmext. — The  treatment  is  symptomatic,  and  does  not  differ  from 
that  of  pneumococcus  lobar  pneumonia  or  of  broncho-pneumonia. 

ACUTE  BRONCHO-PNEUMONIA. 
.     Acute  broncho-  or  lobular  pneumonia  is  an  infection  of  the  lung 
characterized  by  an  inflammation  of  the  walls  of  the  terminal  bronchi 
and  of  the  neighboring  alveoli  which  make  up  a  pulmonary  lobule,  and 
is  so  called  in  contradistinction  to  lobar- pneumonia. 

Etiology. — All  forms  of  broncho-pneumonia  are  produced  by  patho- 
genic organisms.  The  disease  may  be  primary  or  secondary,  acute  or 
chronic.  It  may  occur  at  any  age,  but  is  the  most  common  and  fatal 
form  of  inflammation  of  the  lung  during  the  first  five  years  of  life,  and  is 
much  more  fatal  than  pneumococcus  lobar  pneumonia  during  this  period. 

The  primary  forms  may  attack  children  in  good  health,  and  usually 
under  two  years.  It  is  probable  that  the  pneumococcus  is  usually  the  in- 
fecting organism  in  these  cases,  and  that  the  lobular  rather  than  the  lobar 
type  of  the  disease  is  determined  by  the  greater  susceptibility  of  the  lung 
from  its  embr^-onic  type  to  the  kind  of  inflammatory  lesions  which  char- 
acterize a  broncho-pneumonia.  The  bacillus  of  Friedlander  and  the 
bacillus  of  influenza  produce  this  especial  type  of  pneumonia. 

The  secondary  forms  are  much  more  frequent  than  the  primary  forms, 
and  are  very  apt  to  be  the  result  of  a  mixed  infection  of  streptococci, 
staphylococci,  and  pneumococci.  They  are  especially  fatal  in  infants  and 
young  children.  They  occur  in  connection  with  the  infectious  fevers,  and 
with  the  group  called  the  aspiration  or  deglutition  pneumonias,  which  some- 
times follow  vomiting  of  food,  especially  after  ether,  haemoptysis,  bronchi- 
ectasis, and  empyema.  The  relative  frequency  in  443  cases,  according  to 
Holt,  is  as  follows:  primary,  without  previous  bronchitis,  164;  secondary 
to  measles,  89  ;  whooping-cough,  QQ  ;  diphtheria,  47  ;  bronchitis,  41  ;  acute 
ileo-colitis,  19 ;  scarlet  fever,  7 :  influenza,  6  i  varicella,  2 ;  and  erysipelas,  2. 

Children  who  are  weak  or  debilitated  by  previous  diseases  show  a 
prechsposition  to  broncho-pneumonia,  which  frequently  arises  in  the 
course  of  tuberculosis,  chronic  gastro-enteric  diseases,  and  rhachitis. 
Those  seasons  of  the  year  which  are  marked  by  cold,  moisture,'  and 
variations  of  temperature  especially  predispose  to  the  development  of 
broncho-pneumonia.  All  these  conditions,  however,  in  all  probability 
merely  prepare  the  way  for  the  entrance  of  certain  germs  which  produce 
the  disease.  The  origin  of  broncho-pneumonia  from  intestinal  infection 
must  also  be  considered. 


692 


PEDIATRICS/ 


Pathological  Anatomy. — In  broncho-pneumonia  the  hiflammatory  pro- 
cess affects  the  walls  of  the  smaller  and  terminal  bronchi,  which  become 
thickened  and  markedly  infiltrated  with  cells.  The  inflammatory  process 
tlien  extends  through  the  walls  of  the  bronchi  to  the  surrounding  air  vesi- 
cles as  well  as  to  the  terminal  ones.  In  this  way  centres  of  consolidation 
are  formed  in  different  parts  of  the  lung.  The  course  of  the  inflammation 
varies  in  its  rapidity,  at  times  attacking  only  a  small  portion  of  the  lung, 
and  again  being  more  diffuse  in  its  onset  and  gradually  mvading  large 
areas.  The  lesions  are  irregular  in  their  distribution  and  usually  occur  in 
both  lungs.  They  are  at  times  so  extensive  as  to  involve  a  whole  lobe, 
but,  as  has  been  stated  by  Northrup,  whatever  the  extent  of  hepatization, 
whatever  tlie  time  occupied  in  its  course,  and  whatever  the  post-mortem 
appearances,  the  essential  lesion  is  an  inflammation  of  the  walls  of  the 
terminal  bronchi  and  of  the  adjacent  alveoli. 


Tig.    145. 


Broncho-pneumonia  complicating  measles.    Early  stage.     C.  L.  T.,  consolidated  lung-tissue;  Br.,  bron- 
chiole ;  L.  T.,  emphysematous  lung-tissue. 


Fig.  145  represents  the  section  of  a  lung  made  by  Northrup,  and 
taken  from  an  infant  sixteen  months  old,  in  whom  tlie  broncho-jDneu- 
moiiia  was  a  con^^lication  of  measles.  It  shows  the  early  pathological 
lesions  of  broncho-pneumonia. 

In  one  of  the  lobules  there  are  two  In-onchioles  (Br.j  with  infiltrated 


DISEASES   OF   THE   BRO^XHI   AXD    LUXGS. 


693 


walls  and  pus  within  them.  They  are  also  filled  with  exudation,  and  the 
lumen  of  each  is  almost  entirely  occluded.  A  portion  of  a  neighboring 
lobule  is  consolidated  (C.  L.  T.).  A  considerable  portion  of  the  lung 
tissue  (L.  T.)  m  the  section  is  normal  or  emphysematous. 

Fig.  146  represents  another  section  taken  from  the  lung  of  the  same 
child,  but  showing  the  tissue  relatively  less  affected.     Many  of  the  con- 


Broncho-pneumonia  secondary  to  diphtheria.   Br.,  bronchus ;  C.  L.  T.,  consolidated  lung-tissue; 
N.  L.  T.,  lung-tissue  nearly  normal ;  Art.,  artery. 

solidated  alveoli  contain  free  blood-cells.  The  bronchial  wall  (Br.)  is  in- 
filtrated and  almost  entirely  denuded  of  its  lining  membrane.  These 
smaller  bronchi  are  surrounded  by  zones  of  mtense  congestion  and  infil- 
tration. When  the  inflammation  is  intense  and  is  accompanied  by 
abundant  secretion  these  bronchi  frequently  become  dilated.  This  dila- 
tation is  associated  with  a  weakened  condition  of  the  bronchial  walls  and 
mtli  an  abundant  secretion.  These  dilatations  probably,  according  to  the 
observations  of  Northrup,  wholly  disappear  on  the  recovery  of  the 
patient. 

As  has  already  been  descrilDed  in  the  pathology  of  bronchitis,  the 
bronchial  lymph-nodes  are  always  enlarged  in  broncho-pneumonia,  and 
there  may  be  fibrin  on  the  pulmonary  pleura.  In  the  zones  of  peri- 
brcnchitic    pneumonia   the    walls    of    the  air-vesicles  are  thickened  or 


tjy4  PEDIATRICS. 

SAVollen,  either  with  or  without  some  celhilar  infiltration,  and  tlie  cavities 
of  the  air-vesicles  are  filled  with  epithelial  cells  and  pus-cells,  with  fibrin 
and  red  blood-corpuscles  in  varying  proportion  and  amount.  Fibrin 
when  present  is  only  in  small  quantities,  and  often  is  altogether  absent. 
The  capillaries  in  the  walls  of  the  vesicles  are  congested  and  prominent. 
The  portions  of  lung  which  are  not  hepatized  are  congested  and  oedem- 
atous.  The  cavities  of  the  air-vesicles  are  diminished  by  the  enlarged 
capillaries  and  the  swollen  vesicular  epithelium. 

In  addition  to  the  other  lesions  just  described,  areas  of  atelectasis  are 
frequently  found  in  broncho-pneumonia.  This  atelectasis  is  usually  pro- 
duced by  mechanical  causes,  such  as  obstruction  by  pus  or  tenacious 
mucus.  It  may  also  arise  as  a  result  of  enfeebled  respiratory  power. 
The  blood-vessels  become  dilated,  the  walls  of  the  alveoli  partially  col- 
lapse, the  residual  air  is  absorbed,  and  an  exudation  of  serum  with  pro- 
liferative cells  and  leucocytes  takes  its  place.  The  atelectasis  is  commonly 
symmetrical,  affecting  the  posterior  margin  of  both  lower  lobes  of  the 
lung,  but  it  may  also  appear  in  irregular  scattered  areas  in  the  posterior 
portions  of  the  upper  lobes.  It  may  occur  either  during  the  acute  stage 
of  the  inflammation  or  later  when  the  pneumonia  has  become  chronic. 

There  are  no  distinct  stages  in  the  pathology  of  broncho-pneumonia 
which  correspond  to  those  of  lobar  pneumonia.  Broncho-pneumonia 
develops  by  the  irregular  invasion  of  successive  portions  of  the  lungs, 
and  the  process  resolves  in  like  manner.  The  different  consolidated  areas 
in  the  same  lung  may  often  show  all  the  stages.  The  mottled  appearance 
which  is  so  often  noticed  macroscopically  in  these  lungs  may  be  caused  by 
the  presence  of  lobules  of  gray  and  red  hepatization  lying  side  by  side. 
Of  these  inflammatory  products  the  fibrin  disintegrates  quickly,  and  is 
therefore  absorbed  more  rapidly  than  the  cellular  elements,  which  do  not 
disintegrate  so  readily.  In  lobar  pneumonia,  therefore,  absorption  takes 
place  sooner  than  it  does  in  broncho-pneumonia,  in  which  the  products 
of  inflammation  are  mostly  cellular  and  resolution  and  absorption  are 
naturally  slow. 

Instead  of  the  gradual  disappearance  of  the  various  pathological  lesions 
the  pneumonia  may  persist.  This  persistent  form  of  the  disease  may 
follow  a  single  attack  of  acute  broncho-pneumonia,  or  there  may  be  several 
acute  attacks  before  the  chronic  condition  becomes  evident,  and  the 
course  of  the  disease  may  thus  vary  in  different  cases.  When  this  per- 
sistent broncho-pneumonia  occurs,  the  proliferative  cells  take  part  in  the 
formation  of  new  connective  tissue,  and  in  this  way  persistent  thickening 
is  caused.  The  alveolar  walls  of  certain  portions  may  become  similarly 
thickened.  The  walls  of  the  bronchi  and  their  surrounding  tissue  are  es- 
pecially subject  to  a  persistent  thickening  and  a  formation  of  new  connective 
tissue  constituting  chronic  broncho-pneumonia  and  peribronchitis.  The 
bronchi  already  dilated  become  still  more  enlarged  by  the  contraction  of 
the  cicatricial  tissue  surrounding  them.     The  uneven  contraction  of  this 


DISEASES    OF    THE    BRONCHI    AXD    LUNGS. 


695 


new  tissue,  together  Anth  the  pressure  ^vithin  the  tubes  facilitated  by  a 
weakened  condition  of  the  walls,  allows  of  saccular  as  well  as  of  fusiform 
dilatation  of  the  bronchi.  The  epithelial  cells  of  the  dilated  bronchi  pro- 
liferate, and,  falling  from  the  bronchial  walls,  mix  with  the  bronchial 
secretion.  The  remaining  epithelium  is  swollen  and  loose.  The  lesions 
of  chronic  broncho-pneumonia  are  frequently  associated  with  tuberculosis 
of  the  bronchial  nodes  and  with  other  tubercular  lesions. 

In    connection    with    the    pathological  lesions    occurring   in    chronic 
broncho-pneumonia  a  condition  called  fibroid  phthisis  has  in  very  rare 

Fig.  147. 


Chronic  broncho-pneumonia.    Br.  dl.,  dilated  bronchus  ;  Tli.  L.  T.,  tliickened  lung-tissue 
Br.  Pn.,  broncho-pneumonia. 


cases  been  noticed  in  children.  The  lesions  which  represent  fibroid 
phthisis  are  manifested  by  the  presence  of  connective  tissue  in  the  lung, 
with  a  corresponding  destruction  of  the  true  parenchyma.  These 
changes  are  usually  unilateral,  and  should  not  be  considered  as  repre- 
senting a  disease,  since  they  merely  occur  in  the  course  of  various  chronic 
pulmonary  affections,  among  which  are  tuberculosis  and  chronic  broncho- 
pneumonia. 

Fig.  147  represents  a  section,  also  made  by  Dr.  Northrup,  taken  from 
a  lung  with  chronic  broncho-pneumonia  in  which  the  process  had  ad- 
vanced still  further  than  in  the  other. 


696  PEDIATRICS. 

In  the  middle  of  the  specimen  is  a  dilated  bronchus  with  a  section  of 
a  blood-vessel  just  below  it.  There  is  considerable  connective-tissue 
fonnation  about  both.  In  this  case  the  process  of  a  peribronchitic 
pneumonia  has  gone  further  than  in  the  other  specimen  (Fig.  145),  and 
there  is,  in  addition  to  the  dilated  bronchi  with  the  surrounding  cellular 
infiltration,  a  tendency  to  the  formation  of  connective  tissue  in  the  inter- 
lobular septa.  This  is  the  form  of  chronic  broncho-pneumonia  which  is 
sometimes  called  interstitial  pneumonia,  and  is  usually  characterized  by  a 
long  course  and  delayed  recovery. 

A  frequent  lesion  which  occurs  in  the  course  of  broncho-pneumonia 
is  emphysema.  It  is  usually  vesicular  and  situated  in  the  anterior  portion 
of  the  upper  lobes.  It  is  due  to  the  diminished  amount  of  air-capacity, 
together  with  the  violent  introduction  of  air  into  the  chest  caused  by 
dyspnoea  and  coughing.  This  distention  of  the  air-vesicles  is  supposed 
usually  to  disappear  with  the  subsidence  of  the  lesion  which  is  causing  the 
emphysema.  Emphysema,  both  of  the  vesicular  and  of  the  interstitial 
variety,  most  commonly  occurs  in  the  pneumonia  which  follows  pertussis. 

The  interstitial  variety  may  exist  in  the  form  of  superficial  sacs,  formed 
by  the  rupture  of  air-vesicles  beneath,  which  lift  the  pleura,  or  it  may 
extend  between  the  lobules  in  V-shaped  tracts  from  the  anterior  edge  of 
the  upper  lobe  even  to  the  root  of  the  lung. 

Symptoms. — The  symptoms  of  broncho-pneumonia  vary  greatly  in  their 
onset  and  course,  owing  to  the  many  different  lesions  which  commonly 
occur  in  the  disease  and  wMch  by  their  greater  or  less  severity  make  its 
course  exceedingly  irregular.  In  so  many  instances  the  broncho-pneu- 
monia is  secondary  to  some  other  disease  that  the  symptoms  are  neces- 
sarily modified  by  those  of  the  initial  affection.  Thus,  when  broncho- 
pneumonia arises  in  the  course  of  diphtheria,  the  symptoms  are  often 
obscured  by  the  severity  of  the  general  symptoms  of  the  diphtheria. 
When  broncho-pneumonia  is  secondary'  to  measles  and  to  pertussis, 
although  at  times  its  onset  is  difficult  to  detect,  yet,  as  a  rule,  the  rapid 
respirations,  the  marked  and  continuous  rise  of  temperature,  and  the 
evident  exacerbation  in  the  severity  of  the  pulmonary  symptoms,  usually 
permit  a  diagnosis  to  be  made  even  before  the  physical  signs  have  become 
prominent.  Its  onset,  however,  in  measles  is,  as  a  rule,  rapid,  while  in 
pertussis  it  is  slow  and  insidious. 

The  group  of  symptoms  which  characterizes  a  broncho-pneumonia 
arising  during  the  course  of  bronchitis  is  somewhat  more  definite.  In 
place  of  the  moderate  temperature  and  the  absence  of  signs  of  serious 
disease  which  are  usually  met  with  in  the  course  of  an  ordinarj'  bron- 
chitis, when  broncho-pneumonia  supervenes  the  temperature  rises,  the 
pulse  and  respirations  are  increased  in  frequency,  the  alae  nasi  dilate, 
there  is  more  or  less  cyanosis,  the  cough  becomes  more  frequent  and 
painful,  and  the  general  aspect  of  the  patient  is  that  of  one  suffering  from 
an  affection  of  a  severe  type. 


DISEASES   OF   THE   BRONCHI   AND   LUNGS.  697 

Onset. — The  onset  of  broncho-pneumonia  varies  according  as  the  dis- 
ease is  primary  or  secondary.  In  the  primary  form  the  symptoms  may 
be  mistaken  for  a  lobar  pneumonia.  They  begin  abruptly  with  a  chill  or 
convulsion,  with  a  rapid  rise  in  the  temperature,  which  is  more  constant 
than  in  the  secondary  forms.  The  signs  are  more  local  in  character  and 
the  disease  may  be  masked  by  the  intensity  of  the  cerebral  symptoms. 

The  secondary  form  begins  as  an  inflammation  of  the  bronchioles,  and 
is  not  to  be  distinguished  from  so-called  capillary  bronchitis.,  which  is  essen- 
tially the  same  disease.  The  onset  is  rarely  sudden,  and  there  is  no  chill 
as  a  rule.  It  is  frecfuently  associated  with  one  of  the  infectious  fevers,  oc- 
curring during  the  course  of  the  disease  or  in  early  convalescence,  or  as  a 
result  of  an  inhalation  of  foreign  bodies.  The  child  appears  fretful  and 
restless.  The  temperature  rises  and  is  very  variable.  There  is  cough, 
dyspnoea,  and  rapid  respiration.  The  physical  signs  are  often  limited  to 
scattered  localized  areas  of  fine  and  medium  moist  rales,  and  sometimes 
sonorous  and  sibilant  rales ;  dulness  may  or  may  not  be  present  in  this 
early  stage. 

Temperature. — The  temperature  in  broncho-pneumonia  varies  greatly, 
according  to  the  extent  and  severity  of  the  lesions.  Co-rresponding  to  the 
intensity  of  the  pneumonic  onset,  or  to  the  especial  disease  which  it  com- 
plicates, the  temperature  rises  rapidly  or  slowly  and  insidiously.  The 
most  common  course  in  mild  cases  with  gradual  onset  and  terminating  in 
recovery  is  for  the  temperature  to  rise  gradually  to  39.4°  or  40°  C.  (103° 
or  104°  F.),  then  to  have  a  mornmg  remission  of  three  or  four  degrees 
for  a  number  of  days,  and  finally  to  fall  irregularly  by  lysis.  A  crisis  is 
very  rare  in  broncho-pneumonia,  but  sometimes  occurs  in  the  primary 
form  of  the  disease.  Although  the  remissions  in  the  temperature  during 
the  active  stage  of  the  disease  are  often  quite  marked,  yet,  as  a  rule,  the 
temperature  does  not  at  this  time  fall  to  the  normal.  This  is  of  service 
in  differentiating  certain  cases  of  broncho-pneumonia,  as  well  as  of  lobar 
pneumonia,  from  malaria.  In  the  more  severe  and  unfavorable  cases  the 
temperature  becomes  more  and  more  elevated,  even  reaching  as  high  as 
41.6°  C.  (107°  F.).  Occasionally  the  temperature  is  reversed,  the  highest 
point  being  reached  in  the  morning.  This  is  rare,  and  is  of  no  especial 
significance.  When  the  temperature  instead  of  remitting  remains  high 
and  steadily  rises,  the  disease,  as  a  rule,  soon  terjiiinates  fatally.  Instead 
of  the  continued  high  temperature  which  occurs  so  often  in  fatal  cases, 
a  low  temperature  of  only  a  few  degrees  above  normal  is  sometimes  met 
with,  usually  when  the  vitality  is  low  and  the  power  of  reaction  slight. 
The  duration  of  the  heightened  temperature  is  very  variable,  and  may 
last  for  a  number  of  days  or  for  weeks  without  the  necessary  result  of 
the  grave  lesions  of  a  more  chronic  process. 

Pulse  and  Respiration. — The  pulse  and  respiration,  although  increased 
in  frequency,  vary  according  to  the  severity  of  the  disease  and  also  accord- 
ing to  the  degree  of  nervous  excitement.     This  latter  is  a  very  important 


(jys  PliDIATHIcs. 

element  to  be  considered  in  determining  the  gravity  of  their  rate.  The 
pulse  is  at  times  very  rapid,  160  to  180,  and  even  higher ;  it  usually  varies 
from  130  to  150  or  160  ;  although  regular  and  full  at  first,  it  becomes  weak 
and  sometimes  irregular  as  the  disease  progresses,  and  is  very  apt  to  remain 
rapid  even  after  the  temperature  has  declined  and  convalescence  has  been 
established.  The  respu-ations  may  be  quickened  by  an  unusually  high 
temperature,  but  depend  mostly  on  the  extent  of  the  involvement  of  the 
alveoli.  They  vary  from  50  to  80,  but  they. may  be  even  higher,  and  are 
accompanied  by  dilatation  of  the  alee  nasi. 

The  respiration  often  sho^^^  a  pause  after  inspiration  instead  of  after 
expiration,  as  occurs  in  normal  respiration,  and  is  usually  accompanied  by 
an  expiratory  moan.  This  sign,  however,  is  not  characteristic  of  broncho- 
pneumonia, as  it  may  occur  in  lobar  pneumonia  and  in  various  affections 
in  which  the  circulation  is  interfered  with  and  respiration  is  painful.  In 
like  manner  the  dilatation  of  the  alae  nasi  may  occur  in  any  disease  accom- 
panied by  a  heightened  temperature  and  nervous  excitement.  Temporary 
exacerbations  and  changes  in  the  rhythm  of  respiration  are  quite  common 
in  broncho-pneumonia,  and  in  some  cases  a  Cheyne-Stokes  type  of  res- 
piration has  been  noticed.  This  sign  is  usually  one  of  grave  import.  Re- 
cession of  the  epigastrium  and  of  the  intercostal  spaces  commonly  occurs 
in  broncho-pneumonia,  and  varies  according  to  the  severity  of  the  pulmo- 
nary lesions.  In  infants  painful  respiration  is  shown  by  a  frown  rather 
than  by  crying,  while  in  young  children  it  is  shown  by  their  whimpering 
and  suppressed  cries. 

Cough. — A  frequent,  short,  hacking,  and  painful  cough  is  a  constant 
symptom  from  the  beginning  of  the  disease,  and  even  after  resolution  has 
taken  place  this  may  continue  for  a  long  period.  Infants  and  young  chil- 
dren, even  up  to  the  age  of  seven  or  eight  years,  have  often  not  learned 
to  expectorate,  so  that  we  cannot,  as  in  adults,  judge  of  the  character  of 
the  sputum. 

Gastro-Enteric  Symptoms. — Vomiting  is  at  times  met  with,  and  diar- 
^rhoea  is  not  uncommon.  In  certain  cases  disturbance  of  the  gastro-enteric 
tract  is  present  from  the  very  beginning,  and  the  intestinal  disease  is  ap- 
parently as  prominent  a  feature  of  the  attack  as  the  pulmonary  symptoms. 
As  the  attack  progresses  the  child  loses  much  in  Aveight,  the  face  often 
looks  pinched,  and  at  times  during  the  height  of  the  disease  there  is  a 
certain  amount  of  delirium,  which  in  combination  with  other  grave 
symptoms,  such  as  uncontrollable  diarrhcEa  and  a  depressed  temperature, 
is  a  serious  symptom. 

Cyanosis  and  Dyspncea. — ^A  symptom  which  occurs  quite  commonly 
in  broncho-pneumonia  is  cyanosis.  This  may  not  only  arise  from  the 
interference  with  the  oxygenation  of  the  blood  from  the  lesions  involving 
the  air-vesicles,  but  may  also  be  produced  by  a  temporary  atelectasis  of 
certain  portions  of  the  lungs.  The  cyanosis  is  often  accompanied  by 
attacks  of  dyspnoea.     When  these  symptoms  result  from  atelectasis,  the 


DISEASES    OF   THE    BRONCHI   AND    LUNGS.  (599 

temperature,  as  a  rule,  does  not  rise,  but  may  even  be  somewhat  reduced, 
and  areas  of  dulness  may  be  detected  on  percussion.  During  these 
paroxysms  the  skin  is  often  cold  and  moist.  When  the  cause  of  the 
atelectasis,  whether  it  be  obstruction  by  plugs  of  mucus  or  pus  or  tem- 
porary exhaustion  of  the  contractile  powers  of  certain  portions  of  the 
lungs,  has  been  removed,  the  cyanosis  and  dyspnoea  pass  away  and  the 
general  symptoms  improve.  These  symptoms  may  arise  at  various 
periods  during  the  course  of  broncho-pneumonia,  and  unless  the  atelec- 
tasis passes  off  within  a  few  days  a  fatal  issue  is  very  apt  to  result. 

In  cases  which  recover,  resolution  takes  place  slowly  and  the  lung 
gradually  returns  to  the  normal  condition.  Great  weakness  and  pros- 
tration often  last  for  a  long  time.     Relapses  are  quite  common. 

Blood. — A  leucocytosis  is  generally  present  if  the  broncho-pneumonia 
is  due  to  the  pneumococcus  or  to  mixed  infections,  and  may  be  as  high  as 
40,000,  50,000  or  even  60,000.  When  the  process  is  excited  by  the 
bacillus  of  influenza  or  the  bacillus  of  Friedlander  alone,  the  white  blood 
count  is  either  normal  or  only  slightly  elevated. 

Physical  Signs. — The  physical  signs  of  broncho-pneumonia  are  almost 
entirely  those  of  the  accompanying  bronchitis,  but  in  typical  cases  they 
correspond  to  the  various  pathological  lesions  which  have  been  described. 
According  as  larger  or  smaller  areas  of  the  lung  are  involved,  corre- 
sponding areas  of  dulness  on  percussion  may  be  found,  provided  these 
areas  are  sufficiently  extensive  not  to  be  masked  by  other  resonant  por- 
tions of  the  lungs.  They  can,  as  a  rule,  be  detected  best  by  very  light 
percussion.  These  areas  of  dulness  are  usually  bilateral  and  of  some- 
what varied  extent,  although,  as  has  already  been  stated,  an  entire  lobe 
may  in  rare  instances  be  sufficiently  involved  by  the  broncho-pneumonic 
process  to  produce  very  extensive  areas  of  dulness.  Over  the  area  of 
dulness  bronchial  respiration,  and  in  some  cases  increased  vocal  resonance 
and  fremitus,  may  be  found.  On  auscultation  moist  rales  of  all  grades  may 
be  heard  all  over  the  lungs,  or,  as  is  more  usual,  in  circumscribed  areas. 

Well-marked  physical  signs,  especially  dulness  on  percussion,  are  some- 
times found  at  the  bases  of  both  lungs  behind,  and  also  between  the  scapulae 
and  the  vertebral  column.  The  earliest  changes,  however,  in  percussion 
and  auscultation  are  often  first  detected  in  the  highest  part  of  the  axilla. 
These  signs  of  consolidation  are  rarely  found  in  the  early  days  of  the  dis- 
ease, as  at  this  time  signs  of  bronchitis  are  usually  all  that  can  be  detected. 
The  absence  of  demonstrable  areas  of  dulness  is,  however,  so  very 
common  that  it  is  almost  characteristic.  This  may  be  due  to  the  fact  that 
the  consolidation  is  deep-seated  or  in  such  small  areas  and  so  interspersed 
with  uninvolved  lung-tissue  that  although  superficial  in  distribution  it 
causes  no  perceptible  change  in  the  percussion-note.  The  physical  signs 
are  markedly  modified  when  atelectasis  or  emphysema  is  present. 

Terminations  and  Complications. — Resolution. — If  the  course  of  the 
disease  is  favorable,  the  pathological  process  in  the  areas   of  consolida- 


700  PEDIATRICS. 

tion  terminates  in  resolution,  which  is  often  more  rapid  in  the  individual 
areas  than  in  lobar  pneumonia,  but  may  be  delayed  for  several  days  or 
weeks  as  in  the  latter  affection. 

Siqijmrafion. — Resolution  by  suppuration  is  rare  in  the  more  common 
forms  of  primary  and  secondary  broncho-pneumonias,  and  is  limited 
almost  entirely  to  cases  of  inhalation  or  deglutition  broncho-pneumonias, 
in  which  it  is  very  frec{uent.  Under  the  same  conditions  gangrene  of  the 
lung  may  develop. 

Chronic  Fibroid  Changes. — These  will  be  described  separately  on 
page  705. 

Tuberculosis. — Cases  of  broncho-pneumonia  with  delayed  resolution 
show  a  special  susceptibility  to  infection  by  the  tubercle  bacillus.  This 
complication  will  be  found  more  fully  described  on  page  389. 

Diagnosis. — The  diagnosis  of  broncho-pneumonia  should  first  be  made 
from  the  bronchitis  which  ordinarily  accompanies  it.  This  has  already 
been  sufficiently  referred  to  in  speaking  of  the  diagnosis  of  bronchitis. 

The  differential  diagnosis  between  the  non-tubercular  and  the  tuJDer- 
cular  forms  of  broncho-pneumonia  is  important,  but  can  rarely  be  made  in 
the  early  stages  of  the  disease,  as  the  lesions  are  the  same,  and  a  bacterio- 
logical examination  of  the  sputum  in  these  cases  can  seldom  be  obtained 

The  disease  which  should  be  especially  considered  in  the  diagnosis  of 
broncho-pneumonia  is  lobar  pneumonia.  The  differential  diagnosis  is 
given  in  connection  with  pneumococcus  lobar  pneumonia  on  page  683. 

Prognosis. — Age  is  a  ver}^  important  factor  in  the  prognosis  of  bron- 
cho-pneumonia. As  shown  by  Morrill  a  large  majority  of  the  fatal  cases 
occurs  in  the  first  two  years  of  life,  and  cl'cen  runs  as  high  as  60  or  70  per 
cent.  This  high  death  rate  rapidly  diminishes  after  the  third  year,  but  is 
always  much  greater  than  that  of  lobar  pneumonia.  Broncho-pneumonia 
causes  more  deaths  in  children  than  are  due  directly  to  the  fevers,  and  is 
the  most  serious  complication  of  the  contagious  diseases.  The  prognosis 
varies  according  to  the  disease  in  the  course  of  which  it  arises.  It  is  most 
-grave  when  it  occurs  in  pertussis,  especially  in  infants,  and  the  younger 
the  child  the  more  fatal  the  disease.  Next  to  pertussis,  the  gravity  of  the 
prognosis  is  greatest  in  measles  and  diphtheria.  When  it  occurs  in  such 
diseases  as  rhachitis  and  tuberculosis,  or  when  the  individual  has  not  been 
well  cared  for,  the  prognosis  is  also  very  unfavorable.  The  prognosis  is 
almost  fatal  in  cases  in  which  the  bacillus  of  Friedlander  is  the  exciting 
cause,  and  in  other  forms  when  complicated  with  tuberculosis. 

We  have  already  referred  to  the  temperature  as  a  prognostic  sign  in 
broncho-pneumonia.  According  to  Holt's  observations,  the  highest  mor- 
tality occurs  among  the  cases  of  shortest  duration,  and  the  disease  is 
universally  fatal  when  its  duration  is  shorter  than  four  days.  After  this 
early  period  of  danger  is  passed  the  prognosis  becomes  much  more  favor- 
able, the  lowest  death-rate  in  Holt's  cases  being  met  with  in  cases  termi- 
nating in  from  eight  to  fourteen  days.     When  the  disease  lasts  for  more 


DISEASES   OF   THE   BRONCHI   AND    LUNGS.  701     * 

than  two  weeks  the  chances  of  recovery  are  lessened  every  day  that  the 
temperature  remains  raised.  The  cases  in  which  there  is  a  very  high 
temperature,  41.1°  C.  (106°  F.),  are  usually  fatal.  When  the  disease  is 
protracted,  death  generally  occurs  from  exhaustion. 

Treatment. — The  treatment  of  broncho-pneumonia  is  that  of  the  special 
disease  to  which  it  is  secondary,  and  for  the  most  part  symptomatic.  The 
strength  should  be  carefully  supported  from  the  time  that  the  disease  is 
first  detected  until  convalescence  has  been  completely  established.  The 
patient  should  be  intelligently  nursed,  as  the  nursing  is  the  most  important 
part  of  the  treatment.  The  atmosphere  of  the  room  should  be  equable, 
the  temperature  from  20°  to  21.1°  C.  (68°  to  70°  F.),  and  especial  atten- 
tion should  be  paid  to  the  ventilation.  The  heat  and  ventilation  obtained 
from  an  open  wood-fire  are  especially  valuable,  the  air  being  drawn  from 
windows  which  are  constantly  kept  widely  opened. 

As  few  drugs  as  possible  should  be  given,  since  there  is  no  remedy 
which  will  cut  short  the  disease,  and  most  of  the  drugs  commonly  used 
in  the  treatment  of  pulmonary  affections  are,  as  a  rule,  of  more  harm 
than  benefit  in  broncho-pneumonia.  The  vitality  of  infants  and  young 
children  is  so  easily  lessened  by  a  disease  so  severe  as  broncho-pneumonia 
that  the  respiratory  power  is  likewise  quickly  diminished,  and  we  should 
avoid,  except  when  they  are  especially  needed,  such  drugs  as  opium. 
Ipecac  in  minute  doses  seems  to  facilitate  the  removal  of  the  mucus. 
During  severe  paroxysms  an  atmosphere  of  steam  or  the  administration 
of  oxygen  is  indicated,  according  as  the  symptoms  seem  to  be  produced 
by  a  tenacious  exudate  or  by  unaerated  lung-tissue.  Oxygen  is  also  of 
benefit  in  relieving  the  cyanosis  and  dyspnoea  throughout  the  disease,  and 
may  be  given  for  ten  minutes  every  one  or  two  hours.  In  cases  in  which 
cyanosis  and  dyspnoea  are  urgent,  if  the  symptoms  depend  upon  mechanical 
obstruction  with  its  resulting  atelectasis,  an  emetic  is  occasionally  de- 
manded. In  some  cases,  also,  when  much  exhaustion  arises  from  inces- 
sant coughing,  small  doses  of  tinctura  opii  camphorata  may  be  used  with 
caution,  and  discontinued  as  soon  as  possible.  When  the  urgent  symp- 
toms are  caused  by  the  heightened  temperature,  much  relief  can  be 
obtained  by  means  of  a  bath  given  at  a  temperature  of  32.2°  C.  (90°  F.). 
This  may  be  followed  by  the  warm  Avet  pack,  which  can  often  be  con- 
tinued with  benefit  for  several  hours,  and  is  especially  beneficial  in  pro- 
ducing deep  inspirations  by  which  dependent  portions  of  the  lung  are 
aerated.  In  some  cases  reaction  does  not  take  place,  and  signs  of  ex- 
haustion follow  the  bath.  Under  these  circumstances  phenacetine  may  be 
substituted  for  the  bath.  The  dose  should  be  0.06  to  0.12  gramme  (1  to 
2  grains),  guarded  with  five  or  ten  minims  of  brandy.  This  will  often 
reduce  the  temperature  two  or  three  degrees,  and  in  some  cases  it  will 
remain  down  for  five  or  ten  hours,  during  which  period  the  infant  shows 
a  marked  diminution  of  its  nervous  symptoms.  The  position  of  the  child 
should  be  changed  from  time  to  time,  as  there  is  a  tendency  for  the  in-- 


702 


PEDIATRICS. 


Fig.  148. 


flammatory  exudate  to  collect  in  the  lower  and  back  portions  of  the  lungs. 
The  administration  of  food  at  regular  intervals  is  very  important,  and 
should  be  carried  out  rigorously. 

The  chief  part  of  the  diet,  if  possible,  should  be  milk,  supplemented 
with  broths,  the  food  being  regulated  on  the  general  principles  governing 
feeding  at  different  ages.     Although  vomiting  may  occur  in  certain  cases, 

as  a  rule,  if  the  diet  is  carefully  regu- 
lated and  the  milk  given  once  in  two 
hours  with  stimulants  adapted  to  the 
condition  of  the  especial  case,  an  over- 
sensitive condition  of  the  stomach  is 
seldom  a  serious  obstacle  to  the  treat- 
ment. 

As  the  disease  progresses  it  is 
quite  common  for  the  infants  to  refuse 
their  food.  Feeding  by  means  of  the 
stomach-tube,  preferably  through  the 
mouth,  then  becomes  imperative. 

The  paroxysmal  attacks  of  cyanosis 
and  dyspnoea  may  be  caused  by  a 
weak  heart.  In  these  cases  the  ad- 
ministration of  brandy  and  digitalis, 
the  latter  in  the  form  either  of  tinc- 
ture or  of  infusion,  for  a  few  days, 
until  the  cardiac  condition  has  im- 
proved, is  indicated.  Strychnine  and 
nitroglycerin  may  also  be  used,  the  former  being  considered  especially 
important.  Appropriate  doses  of  alcohol  for  children  of  different  ages  is 
given  on- page  449,  and  those  of  the  other  more  important  cardiac  stimu- 
lants on  page  464. 

When  convalescence  has  been  established  the  children  are  often  left 
in  a  very  weak  condition,  and  special  attention  should  then  be  paid  to  the 
nursing  and  to  the  general  liygiene.  The  restoration  of  strength  should 
be  aided  by  means  of  tonics,  and,  if  possible,  the  child  should  be  removed 
to  an  equable,  warm  climate. 


Acute  bronchi  i-iiiu'Uiii(Hiia.  I'l'inalr,  4)^ 
years  old.  The  black  circles  indicate  areas 
of  consolidated  lung-tissue ;  the  black  spots 
indicate  rales. 


Fig.  148  represents  a  girl,  four  and  one-half  years  old,  in  whom  the  physical  ex- 
amination showed  very  marked  lesions  of  broncho-pneumonia. 

There  Avas  no  tubercular  history  in  her  family.  She  had  scarlet  fever  when  she 
was  one  year  old,  measles  when  she  w^as  one  and  a  half,  pertussis  and  varicella  when 
she  was  three,  and  bronchitis  when  she  was  three  and  a  half  years  old.  She  had 
otherwise  always  been  well,  when  she  began  to  complain  of  headache  and  pain  in  her 
chest.  On  the  ninth  day  of  the  attack  she  vomited,  and  two  days  later  began  to  cough 
and  to  be  rather  somnolent.  Her  bow-els  were  regular.  On  physical  examination  the 
child  was  found  to  be  rhachitic,  as  shown  by  a  rosary,  enlarged  epiphyses  of  the  wrists 
and  ankles,  and  marked  bowing  of  the  legs.  On  entering  the  hospital  her  pulse  was 
160,  her  respirations  60,  and  her  temperature  ?>9A°  C.  (108°  F.)  in  the  morning  and 


DISEASES    OF    THE    BRONCHI    AND    LUNGS.  703 

40°  C.  (104°  F.)  in  the  evening.  Slie  seemed  very  sick,  had  considerable  cough,  but  no 
expectoration  ;  there  was  some  dyspnoea,  and  at  times  she  was  somewhat  cyanotic. 
On  examining  the  chest  the  percussion  was  found  to  be  resonant,  but  throughout  both 
lungs  there  were  moist  rales.  Nothing  abnormal  was  detected  on  examining  the  heart 
and  abdomen.     She  was  treated  with  milk  and  brandy. 

On  the  following  day  she  was  in  about  the  same  condition,  and  her  pulse,  respira- 
tions, and  temperature  were  the  same  as  when  she  entered  the  hospital.  In  certain 
circumscribed  areas  in  both  backs  slight  dulness  was  detected  on  percussion,  with 
moist  rales  around  the  edges  of  these  areas. 

On  the  third  day  the  pulse  had  fallen  to  136,  the  respirations  to  40,  and  the  tem- 
perature to  38.3°  C.  (101°  F.).  On  the  ninth  day  of  the  disease  the  pulse  was 
stronger  and  the  child's  condition  was  very  much  improved.  The  dyspnoea  had  dis- 
appeared almost  entirely,  there  was  no  cyanosis,  and  she  was  more  comfortable.  The 
front  of  the  chest  showed  the  resonance  on  percussion  to  be  normal,  and  no  abnormal 
sounds  on  auscultation.  On  examining  the  .  back  certain  circumscribed  areas  of 
dulness  were  found,  the  borders  of  which  are  marked  in  black.  One  of  these  areas 
was  between  the  edge  of  the  scapula  and  the  vertebral  column,  another  was  at  the 
right  base  in  the  posterior  axillary  region,  and  another  at  the  left  base  just  below  the 
angle  of  the  scapula.  Over  these  areas  of  dulness  bronchial  respiration  was  heard. 
Just  outside  of  the  areas  of  dulness  moist  rales  of  various  sizes,  which  are  indicated 
by  black  dots,  could  be  heard  in  limited  areas.  The  physical  signs  corresponded  in 
their  distribution  to  the  areas  in  which  the  lesions  of  this  disease  are  usually  detected 
on  physical  examination. 

On  the  fourteenth  day  the  child  was  found  to  have  much  improved.  During  the 
following  ten  days  the  abnormal  signs  in  the  chest  disappeared,  but  the  pulse,  res- 
pirations, and  temperature  did  not  become  permanently  normal  for  a  week  later.  The 
child,  after  remaining  weak  and  debilitated  for  some  time,  was  finally  discharged 
from  the  hospital  in  good  condition.  The  temperature,  pulse,  and  respirations  declined 
by  lysis  on  the  ninth  day  of  the  disease  and  reached  the  normal  on  the  twelfth  day. 

This  case  apparently  arose  in  tlie  course  of  a  slight  bronchitis  occur- 
ring in  a  rhachitic  child.  The  prognosis  of  broncho-pneumonia  in  rha- 
chitis  is  usually  unfavorable,  but  in  this  case  the  child  possessed  sufficient 
vitality  not  to  succumb  to  the  disease. 

The  following  case  illustrates  the  gravity  of  broncho-pneumonia  when 
it  occurs  in  a  rhachitic  child. 

The  child  was  two  years  and  one  month  old.  Its  mother  died  of  pulmonary 
tuberculosis.  It  had  bronchitis  when  it  was  one  year  old,  and  the  cough  continued  for 
three  months.  One  week  before  entering  the  hospital  it  was  attacked  with  a  severe 
cough,  and  began  to  lose  in  weight  and  to  have  diarrhoea.  A  physical  examination 
showed  that  it  was  a  case  of  marked  rhachitis.  The  breathing  was  rapid  and  labored, 
there  was  considerable  cyanosis,  and  the  child  ^vas  dull  and  somnolent.  Patches  of 
dulness  were  found  in  various  parts  of  the  lungs,  with  moist  rales  of  different  sizes. 
The  pulse  varied  from  140  to  150,  the  respirations  from  80  to  90,  and  the  temperature 
from  38.8°  to  40°  C.  (102°  to  104°  F.).  The  symptoms  increased  in  severity,  the 
child  grew  weaker,  and  on  the  second  day  after  it  entered  the  hospital  it  died  suddenly. 

When  broncho-pneumonia  attacks  a  child  with  such  marked  rhachitis 
as  was  shown  in  this  case,  a  fatal  issue  almost  always  results. 

The  next  case  was  that  of  a  girl,  two  years  old,  who  previously  had  been  well  and 
strong  until  she  was  attacked  with  measles.     There  was  no  tubercular  history  in  the 


704 


PEDIATRICS. 


family.  On  the  fifth  day  of  the  measles  her  temperature  was  39.8°  C.  (103.7°  F.),  the 
pulse  was  120,  and  the  respirations  were  62.  An  examination  of  the  chest  showed  the 
heart  to  be  normal,  the  percussion  normal,  and  the  respiration  harsh,  with  numerous 
fine  and  coarse  moist  rales  throughout  botli  lungs.  Nothing  else  abnormal  was  detected. 
The  temperature  fell  by  a  sharp  crisis  on  the  sixth  day  and  remained  normal  for 
two  days,  during  which  the  efflorescence  rapidly  faded  and  the  patient  seemed  better, 

though  she  occasionally  had  a  harsh 
CHART  31.  cough.     On  the  ninth  and  tenth  days 

she  had  a  slight  rise  of  temperature, 
lint  there  were  no  marked  symptoms 
until  the  eleventh  day,  when  the  tem- 
perature rose  to  40°  C.  (104°  F.),  the 
pulse  to  160,  and  the  respirations  to 
50.  She  was  very  restless,  and  had 
considerable  dyspnoea.  She  was  pal- 
lid and  sometimes  slightly  cyanotic. 
On  physical  examination  there  was 
found  diminished  resonance  over  an 
area  in  the  lower  part  of  the  left  back. 
Over  this  area  the  breathing  was 
bronchial,  and  there  was  also  a  num- 
ber of  moist  rales.  On  the  right 
side  of  the  thorax,  especially  at  the 
base  of  the  lung,  there  were  numer- 
ous coarse  moist  rales  and  harsh  res- 
piration, but  no  dulness.  Chart  31 
shows  the  course  of  the  temperature, 
pulse,  and  respiration  during  the 
twelve  days  of  the  broncho-pneu- 
monia. The  pulse  continued  to  be 
rapid  and  the  respirations  to  be  some- 
what raised  for  some  days  after  the 
temperature  became  normal.  The 
abnormal  signs  in  the  chest  disap- 
peared, and  the  child  made  a  rapid 
recovery. 

This    case    illustrates   the    rapid 
development  of  a  broncho-pneumonia 
during  an  attack  of  measles,  occur- 
ring after  the  temperature  produced 
by  measles  had  fallen  to  the  normal 
and  while  the  efflorescence  was  dis- 
appearing.     The  physical  signs  showed  the  presence  of  small  areas  of  consolidation  in 
the  left  lung,   and  the  usual  diffuse  bronchitis  throughout  the  right  lung  and  parts  of 
the  left  lung. 


1 — 

Days  of  Disease. 

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_ 

Broncho-pneumonia  following  crisis  of  measles. 
2  years  old. 


Child, 


Chronic  Broncho-Pneumonia. — In  a  certain  number  of  cases,  after  a 
child  has  had  an  attack  of  acute  bronclio-pneumonia  the  physical  signs  of 
consohdation  may  persist,  altliough  apparent  recovery  has  taken  place  so 
far  as  the  general  symptoms  are  concerned.  When  this  occurs  the  fever 
may  return  after  a  variable  period,  and  the  child,  after  having  become 
still  more  emaciated,  may  die  after  a  number  of  months  of  exhaustion. 


DISEASES   OF   THE   BRONCHI   AND   LUNGS.  705 

These  cases  are  very  apt  to  be  associated  with  a  tubercular  broncho- 
pneumonia which  may  eventually  heal  by  the  production  of  fibroid  cica- 
trices, but  the  most  common  termination  of  these  cases  is  in  acute  general 
miliary  tuberculosis.  Instead  of  this  fatal  issue,  the  child,  as  has  been 
show^n  by  Delafield,  may  be  left  with  a  chronic  form  of  the  disease,  which 
may  last  for  many  years  and  be  accompanied  by  symptoms  of  cough, 
dyspnoea,  and  at  times  periods  of  fever.  Broncho-pneumonia  of  a  sub- 
acute or  of  a  chronic  type  is  so  apt  to  develop  in  the  lungs  of  young  children 
during  the  course  of  any  disease  of  a  prolonged  nature  that  frequent 
examinations  of  the  lungs  should  be  made,  in  order  that  the  insidious 
development  of  these  pulmonary  lesions  may  not  be  overlooked. 

Treatment. — The  treatment  of  these  chronic  cases  of  broncho-pneu- 
monia is  essentially  symptomatic  and  climatic.  The  child  should  be 
taken  to  a  warm,  dry  climate  of  high  altitude,  where  it  can  live  in  the 
open  air  and  where  it  will  not  be  subjected  to  frequent  atmospheric 
changes, 

HYPOSTATIC  PNEUMONIA. 
*  Hypostatic  pneumonia  is  an  extreme  degree  of  passive  congestion 
which  occurs  in  the  course  of  many  long-continued  diseases,  such  as 
typhoid  fever.  The  dependent  portions  of  the  lungs  become  engorged 
with  blood  and  the  alveoli  partially  filled  with  accumulated  alveolar  cells, 
so  that  the  condition  resembles  a  consolidation.  It  occurs  especially  in 
patients  whose  vitality  has  been  greatly  lowered  by  a  prolonged  illness, 
and  who  are  kept  too  long  in  one  position  without  being  turned. 

The  physical  signs  are  those  of  slight  dulness  on  percussion,  generally 
at  the  base  of  the  posterior  lobes,  diminished  tactile  fremitus,  and  feeble 
respirations  and  voice-sounds.  Moist  rales,  generally  bilateral,  are  heard 
over  the  areas  of  dulness,  but  fever,  pain,  and  cough  are  absent. 

The  condition  is  recognized  by  the  presence  of  the  primary  disease  and 
by  the  gradual  development  of  the  physical  signs  without  the  characteristic 
features  of  pneumonia  or  pleurisy.  It  may,  however,  give  no  evidence 
of  its  presence  during  life,  and  may  be  discovered  only  at  the  autopsy. 

Treatment. — The  treatment  is  chiefly  prophylactic  during  the  course 
of  the  primary  disease.  The  nurse  should  see  that  the  child  is  not 
aUowed  to  lie  in  one  position  for  more  than  two  hours.  The  condition 
calls  for  active  stimulation. 

ATELECTASIS. 
Atelectasis  is  a  collapsed  and  unaerated  condition  of  the  air-vesicles. 
It  may  be  congenital  or  acquired. 

Congenital  Atelectasis. — Congenital  atelectasis  arises  because  the 
infant  has  not  sufficient  general  vitality  and  respiratory  power  at  birth  to 
inflate  fully  all  parts  of  its  lungs.  There  may  be  an  obstruction  by 
mucus.  There  are  in  all  these  cases  areas  of  uninflated  pulmonary 
vesicles  of   varying  extent.     These  vesicles  at  the  post-mortem  exami- 

45 


706  PEDIATRICS. 

nation  can  easily  be  artificially  distended  and  then  cannot  be  distinguished 
from  those  which  have  been  normally  inflated. 

Symptoms. — The  symptoms  of  congenital  atelectasis  are  cyanosis, 
dyspnoea,  rapid  respiration,  rapid,  feeble,  and  often  intermittent  pulse,  a 
temperature  usually  lowered,  and  dulness  on  percussion  with  lessened 
respiration  over  the  area  of  atelectasis.  These  are  the  typical  physical 
signs,  but  in  many  cases  some  or  all  of  these  signs  are  absent  and  the 
condition  is  detected  only  at  the  post-mortem  examination. 

Acquired  Atelectasis. — Acquired  atelectasis  is  a  symptom  of  a  num- 
ber of  diseases,  and  occurs  especially  in  severe  cases  of  bronchitis  in 
.which  the  smaller  bronchi  are  involved,  also  in  broncho-pneumonia  and 
in  pertussis.  Acquired  atelectasis  undetected  during  life  is  frequently 
found  at  the  post-mortem  examination  of  infants  and  young  children 
dying  of  almost  any  disease. 

Prognosis. — The  prognosis  in  these  cases  varies  according  to  the  ex- 
tent of  the  pulmonary  tissue  involved  and  the  vitality  of  the  infant.  As 
a  rule,  the  prognosis  is  very  unfavorable. 

Treatment. — The  treatment  of  atelectasis  is  to  stimulate  the  infant,  and 
to  endeavor  to  raise  its  temperature  by  means  of  a  warm  pack.  In  a  num- 
ber of  cases  we  have  found  the  administration  of  small  quantities  of  oxygen 
to  be  of  benefit.  Artificial  inflation  of  air-vesicles  has  not  proved  to 
be  an  especially  valuable  form  of  treatment.  Many  cases  of  atelectasis 
may  be  avoided  if  the  physician  appreciates  the  importance  of  making  an 
infant,  in  the  first  few  minutes  after  birth,  thoroughly  expand  its  lungs  by 

vigorous  crying. 

EMPHYSEMA. 

Emphysema  is  an  over-distention  of  the  alveoli  and  infundibula  of  the 
lungs.  It  is  always  a  secondary  process.  Various  descriptive  terms  have 
been  used  to  denote  differences  in  the  type  of  the  disease. 

Compensatory  emphysema  consists  in  a  dilatation  of  the  alveoli  in 
certain  portions  of  the  lung  as  a  result  of  obliteration  of  the  function  of 
other  parts  by  consolidation,  adhesions,  or  pressure  of  deformed  bones. 
This  condition  is  likely  to  occur  in  connection  Avith  pneumonia,  tuber- 
culosis, chronic  adhesive  pleurisy,  or  rhachitis. 

Obstructive  emphysema  represents  the  same  pathological  lesions,  but 
the  cause  lies  in  some  obstruction  to  expiration,  as  in  stenosis  of  the 
larynx,  asthma,  and  pertussis. 

Interstitial  emphysema  occurs  rarely  as  a  result  of  a  rupture  of  the 
walls  of  the  alveoli,  by  which  the  air  works  through  the  interstitial  tissue 
of  the  lung  into  the  subcutaneous  tissue. 

Symptoms. — Hyperresonance  on  percussion,  feeble  breathing,  pro- 
longed expiration,  diminution  in  tactile  fremitus  and  voice-sounds  are  the 
physical  signs  of  emphysema.  The  normal  area  of  cardiac  dulness  may 
be  much  diminished  by  the  overlapping  emphysematous  lung ;  in  the 
^ame  way  the  upper  border  of  the  liver  dulness  may  be  considerably 


DISEASES   OF   THE   PLEURA.  707 

lowered.     The  symptoms  are  those  of  the  disease  m  which  the  emphy- 
sema occurs. 

Treatment. — The  treatment  should  be  adapted  to  the  underlying  con- 
dition. 

GANGRENE  AND  ABSCESS   OF  THE  LUNG. 

Gangrene  and  abscess  of  the  lungs  are  represented  essentially  by  the 
same  clinical  symptoms,  and  may  occur  in  connection  with  lobar  or 
broncho-pneumonias.  They  are  caused  by  the  action  of  suppurative  and 
putrefactive  bacteria  which  invade  the  affected  portions  of  the  lung  with 
the  production  of  small  or  large  abscesses. 

Gangrene  is  diagnosticated  chiefly  by  the  presence  of  putrid,  purulent 
sputum  containing  elastic  fibres.  It  is  to  be  distinguished  from  fetid 
bronchitis,  which  does  not  contain  the  elastic  fibres  of  the  lung-tissue. 

The  rupture  of  an  empyema  into  a  bronchus,  with  the  resulting  ex- 
pectoration of  purulent  sputum,  simulates  the  condition  of  abscess,  but 
the  diagnosis  should  be  made  by  the  physical  signs  of  empyema.  The 
treatment  is  that  of  the  primary  disease. 

DISEASES   OF   THE   PLEURA. 

Inflammations  of  the  pleura  may  be  primary  or  secondary,  acute  or 
chronic,  and  with  or  without  an  exudation. 

ACUTE  PLEURISY. 

Etiology. — Acute  pleurisy,  either  with  a  simple  exudation  of  fibrin  or 
accompanied  by  fluid,  is  not  infrequent  in  children  in  the  winter  and 
early  spring. 

Primary  forms  occur,  but  are  very  rare,  and  are  attributed  to  exposure 
to  cold  or  to  injury,  as  from  penetrating  wounds  and  fractured  ribs. 

Secondary  forms  are  the  rule ;  they  occur  by  direct  extension  in  con- 
nection with  lobar  pneumonia,  broncho-pneumonia,  tuberculosis  of  the 
lungs,  pulmonary  embolism,  pericarditis,  peritonitis,  or  some  neighboring 
local  inflammation.  They  may  also  be  caused  by  metastatic  infections 
from  distant  inflammatory  processes,  by  means  of  the  blood-vessels  or 
lymphatics,  or  in  the  course  of  acute  infectious  fevers.  Pleurisy  may  also 
occasionally  be  associated  with  nephritis  and  syphilis. 

The  bacteriology  of  inflammations  of  the  pleura  includes  many  varie- 
ties of  organisms.  The  pneumococcus  is  found  in  the  great  majority  of 
cases  of  pleurisy  in  early  life  and  is  generally  accompanied  by  a  purulent 
exudation  ;  these  cases  are  apt  to  arise  in  connection  with  pneumonia  and 
run  a  favorable  course.  The  streptococcus  pyogenes  causes  a  much  more 
serious,  and  often  fatal,  purulent  infection,  but  is  less  common  in  children 
than  in  adults. 

Tubercular  pleurisy  is  rare  in  infancy,  but  occurs  more  frequently  in 
the  later  vears  of  childhood.     Eichhorst  has  shown  in  one  series  of  serous 


708  PEDIATRICS. 

exudations  that  nearly  sixty-five  per  cent,  of  the  cases  were  tubercular, 
but  the  pneumococcus,  cliplococcus,  and  staphylococcus  are  sometimes 
found  in  these  non-purulent  exudations.  The  staphylococcus,  gono- 
coccus,  Friedlander's  bacillus,  colon  bacillus,  and  typhoid  bacillus  have 
occasionally  been  cultivated  from  the  purulent  exudations. 

In  acute  inflammations  of  the  pleurae  we  can  make  a  clinical  dis- 
tinction between  three  types  of  the  disease,  based  upon  differences  in 
the  pathological  lesions:  (a)  acute  dry  or  i)lastic  pleurisy,  (6)  acute 
pleurisy  with  sero-fibrinous  exudation,  and  (c)  acute  pleurisy  with  puru- 
lent exudation  (empyema). 

Acute  Dry  or  Plastic  Pleurisy. — Pathology. — The  pleura  is  injected 
and  without  lustre.  At  first  it  is  covered  with  a  thin  layer  of  lymph, 
which  becomes  opaque  and  thickened  by  the  deposition  of  fibrin  and 
leucocytes.  The  sub-pleural  fibrous  tissue  is  also  thickened  by  the  exuda- 
tion of  serum  and  by  cellular  infiltration.  The  roughened  surfaces  of  the 
visceral  and  parietal  layers  may  adhere,  forming  loose  connections  which 
may  subsequently  undergo  organization  without  producing  an  exudation 
and  end  m  a  chronic  adhesive  pleurisy.  The  areas  of  inflamed  pleura 
may  be  large  or  small  and  diffusely  located.  They  may  rarely  occur  at 
the  apices  of  the  lungs  in  connection  with  an  early  tubercular  process. 
On  the  other  hand,  they  may  be  limited  to  the  base  and  give  rise  to 
diaphragmatic  pleurisy. 

The  term  pleuro-pneumonia  has  been  applied  to  those  cases  of  dry 
pleurisy  in  which  there  has  been  an  excessive  exudation  and  deposition 
of  pus-cells  in  the  layer  of  fibrin  without  the  formation  of  free  fluid  in 
the  pleural  cavity. 

Symptoms. — Although  localized  areas  characterized  by  the  production 
of  fibrin  are  quite  frequently  found  at  the  post-mortem  examination,  the 
diagnosis  of  this  form  of  disease  in  infants  and  in  young  children  is  not 
often  made  during  life.  The  symptoms  are  of  acute  onset,  characterized 
by  a  sharp  pain  or  stitch  in  the  side,  slight  fever,  and  a  short,  dry  cough. 
-The  pain  is  usually  referred  to  the  lower  part  of  the  axilla,  where  the 
largest  excursions  of  the  two  layers  of  the  pleura  take  place  in  the  act 
of  breathing,  or  to  the  abdomen.  On  auscultation  a  friction-rub  may  be 
heard  at  the  site  of  the  pain  or  remote  from  it.  In  infants  and  young 
children,  however,  friction-sounds  and  pleuritic  pain  are  much  less  pro- 
nounced than  in  adults,  and  a  pleurisy  is  often  not  even  suspected  until 
the  advent  of  the  exudation.  Probably  in  the  great  majority  of  cases  of 
dry  pleurisy  in  early  life  the  condition  is  secondary  to  lobar  or  broncho- 
pneumonia, and  its  signs  and  symptoms  may  be  masked  by  those  of  the 
primary  disease. 

Acute  Pleurisy  with  Sero-Pibrinous  Exudation. — Pathological 
Anatomy. — The  pathological  exudate  of  a  dry  or  plastic  pleurisy  may  be 
directly  absorbed  or  the  inflammation  may  result  in  an  exudation  of 
serum  and  fibrin  into  the  pleural  cavities  with  organization. 


DISEASES   OF   THE   PLEURA.  709 

The  fluid  is  of  a  clear,  pale-yellow  color,  coagulates  spontaneously, 
and  contains  flocculi  of  fibrin  and  a  few  leucocytes  and  endothelial  cells. 
The  amount  of  fibrin  varies,  and,  according  as  it  is  small  or  large  in 
relation  to  the  serum,  we  speak  of  the  exudate  as  sero-fibrinous  or 
fibrino-serous.  A  greater  proportion  of  fibrin  is  likely  to  be  present  in 
the  exudation  in  children  than  in  adults. 

The  quantity  of  fluid  may  be  small  and  encysted,  and  accompanied 
by  areas  of  atelectasis  in  the  adjacent  lung,  or  it  may  fill  the  whole  cavity, 
compressing  the  lung  against  the  spine,  and  thus  practically  depriving  it  of 
its  functions.  In  a  similar  manner  when  the  exudation  is  on  the  right  side 
the  liver  is  depressed.  Displacements  of  the  heart  and  pericardium  very 
commonly  occur  when  the  exudation  is  either  on  the  right  or  the  left  side. 

Symptoms, — The  onset  of  acute  pleurisy  with  serous  exudation  is  in 
many  cases  violent,  and  attended  by  a  high  temperature,  increased 
respirations,  rapid  pulse,  restlessness,  and  even  pain,  which  in  young 
children  is  usually  referred  to  the  abdomen.  In  infants  and  in  young 
children  convulsions  are  c^uite  common,  while  in  older  children  the 
symptoms  are  more  like  those  which  occur  in  adults.  There  is  a  short, 
painful  cough,  with  loss  of  appetite,  and  frequently  vomiting  and  diarrhoea. 

The  white  blood  count  is  rarely  increased  in  serous  exudations,  except 
in  the  febrile  stages,  and  even  then  is  not  often  over  thirteen  thousand. 
Uncomplicated  cases  of  tubercular  pleurisy  probably  never  have  a  leuco- 
cytosis  (Cabot). 

These  early  symptoms  are  usually  follow^ed  in  two  or  three  days  by 
an  exudation  and  by  a  decided  lessening  of  the  pain  and  dyspnoea.  At 
the  same  time  the  temperature  begins  to  have  a  decided  morning  re- 
mission. When  the  exudation  is  large,  the  children  lie  more  comfortably 
on  the  affected  side,  and  when  they  are  nursing  they  nurse  most  easily 
from  the  right  breast  if  the  left  pleura  is  affected,  and  from  the  left  breast 
if  the  right  pleura  is  affected.  After  the  serous  exudation  has  remained 
for  a  few  days  it  ordinarily  begins  to  lessen  in  amount,  absorption  takes 
place,  and  by  the  end  of  a  week  or  ten  days  it  is  entirely  absorbed  and 
the  child  recovers.  In  other  cases  it  becomes  chronic  unless  its  absorption 
is  furthered  by  aspiration. 

Physical  Signs. — The  physical  signs  of  fluid  in  the  pleural  cavity 
differ  in  certain  respects  from  the  usual  signs  in  adults. 

Inspection. — On  inspection  we  find  diminished  movement  of  the 
affected  side  on  inspiration,  and  if  the  fluid  is  large  in  amount,  a  decided 
bulging.  The  impulse  of  the  apex  beat  is  often  displaced,  depending 
on  the  quantity  of  the  exudation  and  the  side  affected.  The  displace- 
ment of  the  heart  is  most  marked  in  left-sided  effusions,  in  which  the 
impulse  may  be  seen  in  the  third  and  fourth  right  intercostal  spaces,  and 
sometimes  as  far  out  as  the  mammillary  line.  In  right-sided  effusions  the 
degree  of  displacement  is  less,  but  the  impulse  may  be  seen  in  the  fourth 
interspace  and  between  the  mammillary  and  midaxillary  lines. 


710  PEDIATRICS. 

Palpation. — By  palpation  the  intensity  of  the  apex  beat  and  the 
amount  of  displacement  of  the  heart  and  of  the  liver  (in  right-sided 
affections)  may  be  determined.  The  information  to  be  obtained  by  tactile 
fremitus  is  not  of  much  A'alue  in  infancy  and  early  childhood ;  its  diminu- 
tion is  not  marked,  and  occasionally  it  is  quite  distinct  over  an  exudation. 
Thus  one  of  the  most  valuable  of  differential  signs  from  consolidation 
fails  in  the  doubtful  cases  in  children. 

Percussion. — The  percussion-note  varies  from  slight  dulness  to  flat- 
ness, according  to  the  cjuantity  of  the  fluid,  and  there  is  a  sense  of  in- 
creased resistance  to  the  fingers.  Above  this  level  of  dulness  the  note 
is  normal  or  tympanitic  (Skoda's  resonance),  and  may  be  most  pronounced 
in  front  below  the  clavicles.  On  the  right  side  the  dulness  may  be  con- 
tmuous  with  that  of  the  liver,  on  the  left  it  may  obliterate  the  semilunar 
space  of  Traube. 

The  upper  border  of  a  fluid  exudate  has  certain  peculiar  character- 
istics, as  shown  by  Ellis  and  Garland,  if  not  complicated  by  pleural  adhe- 
sions, and  is  often  of  aid  in  the  differential  diag-nosis  from  consolidation 
of  the  lung.  When  the  fluid  is  small  in  amount  it  can  usually  first  be 
detected  in  the  back.  In  these  small  exudations  the  upper  border  of 
dulness  begins  at  the  vertebral  column,  extends  outward  horizontally  for 
a  distance  which  varies  according  to  the  size  of  the  exudation,  and  drops 
in  the  neighborhood  of  the  posterior  axillary  line,  by  a  curve  more  or  less 
abrupt,  to  the  base  of  the  thorax.  As  the  fluid  increases  in  size  the  line 
of  dulness  drops  more  anteriorly.  When  it  is  moderate,  the  lower  half 
of  the  pleura  only  being  filled,  the  upper  border  of  the  area  of  dulness  is 
found  to  extend  at  first  outward  and  then  upward  over  the  angle  of  the 
scapula,  reaching  its  highest  point  in  the  axillary  region.  The  line  may 
then  drop  abruptly  from  the  upper  axilla  to  the  base  of  the  thorax  near 
the  apex  of  the  heart  or  to  the  corresponding  point  on  the  right  side.  This 
line,  which  has  been  called  the  '^  letter  S  curve,"  is  characterized  by 
having  its  highest  point  in  the  axillary  line.  When  the  quantity  of  fluid 
is  still  larger  and  exceeds  a  certain  amount,  the  "  letter  S  curve"  is 
obliterated,  and  the  resonance  over  the  compressed  lung  becomes  less 
marked.     This  curve  can  only  be  determined  by  very- light  percussion. 

If  the  line  of  dulness  is  altered  by  a  change  in  position  of  the  body, 
it  is  a  positive  sign  of  fluid.  An  encysted  exudation  or  a  large  amount 
of  fluid  will  not  give  this  sign. 

The  displacement  of  the  heart  is  a  most  valuable  indication  of  effusion 
in  young  children,  and  with  careful,  light  percussion  the  gradual  increase 
and  decrease  of  the  effusion,  when  it  is  of  any  great  extent,  can  be  de- 
termined by  the  variations  in  the  position  of  the  heart.  The  physio- 
logical dulness  of  the  heart  which  has  been  described  as  occurring  in 
early  childhood  (page  85)  under  the  lower  third  of  the  sternum,  becomes 
much  more  marked  when  the  heart  is  displaced. 

Auscvltation. — The  sounds  obtained  by  auscultation  are  variable,  and 


DISEASES   OF   THE   PLEURA.  711 

in  some  respects  are  very  different  from  those  which  are  heard  over  a 
pleural  exudation  in  an  adult.  Bronchial  breathing  is  the  rule  rather 
than  the  exception.  It  is,  however,  less  intense  and  more  distant  than 
that  which  we  ordinarily  hear  over  an  area  of  consolidation.  Vocal  reso- 
nance, moreover,  is  generally  increased  (bronchophony),  and  is  some- 
times as  pronounced  as  in  pneumonia.  Occasionally  it  will  give  the 
same  nasal  quality  as  over  a  consolidation.  Friction-sounds  above  the 
level  of  the  fluid,  or  after  absorption,  are  rare  in  early  life.  Moist  rales 
are  sometimes  heard  over  an  exudation,  and  are  probably  of  bronchial 
origm.  Even  friction-sounds  are  sometimes  said  to  be  heard  over  the 
fluid,  but  are  probably  transmitted  from  points  above  the  level  of  the 
exudation. 

Diagnosis. — The  principal  physical  signs  of  pleural  effusion  in  infancy 
and  early  childhood  are  flatness  which  does  not  correspond  to  the  ana- 
tomical divisions  of  the  lobes  of  the  lung,  bronchial  breathing,  varying  in 
intensity,  bronchophony,  displacement  of  the  heart,  and  changes  in  the 
outline  of  dulness  on  shifting  the  position  of  the  body.  The  differential 
diagnosis  can  best  be  described  in  connection  with  purulent  exudations 
(page  713). 

Prognosis. — The  prognosis  of  a  serous  effusion,  as  a  rule,  is  very  favor- 
able in  infants  and  in  young  children  unless  the  streptococcus  or  one  of 
the  more  virulent  forms  of  the  pyogenic  cocci  is  present,  or  unless  the 
disease  is  secondary'  to  tuberculosis  elsewhere  and  is  caused  by  the  tubercle 
bacillus.  If  the  serous  exudation  tends  to  become  purulent,  the  prognosis 
is  not  so  good,  but  still,  provided  appropriate  treatment  is  carried  out,  it 
is  favorable.  If,  as  in  rare  cases,  the  pleuritic  exudation  occurs  on  both 
sides,  the  prognosis  becomes  grave.  The  possDjility  of  the  presence  of 
the  tubercle  bacillus  should  be  considered  in  these  latter  cases. 

We  had  in  our  service  at  the  Boston  City  Hospital  a  boy,  thirteen  years  old,  who  was 
attacked  with  pleurisy  and  a  serous  exudation  on  the  left  side  wi!h  displacement  of  the 
heart  to  the  right.  After  one  aspiration  the  fluid  was  quickly  absorbed,  but  three 
weeks  later  he  was  attacked  with  pleurisy  on  the  right  side,  followed  by  an  exudation 
and  displacement  of  the  heart  to  the  left.  This  effusion  was  absorbed  without  aspira- 
tion, and  the  boy  was  discharged  from  the  hospital  well  and  strong,  with  both  lungs 
apparently  in  a  normal  condition. 

When  the  effusion  is  very  large  and  the  heart  is  much  displaced,  there 
is  always  the  danger  of  a  fatal  issue  from  asphyxia,  and  the  prognosis  de- 
pends upon  whether  the  exudation  can  be  controlled  by  aspiration  and 
the  heart  thus  be  kept  in  normal  position.  The  following  case  illustrates 
the  danger  which  may  arise  when  these  large  ciuantities  of  fluid  are 
accompanied  by  displacement  of  the  heart. 

A  boy,  four  or  five  years  old,  entered  the  hospital  with  a  large  exudation  in  the 
left  chest.  The  heart  was  displaced  to  the  right  and  upward  as  far  as  the  second 
interspace  to  the  right  of  the  sternum.      He  was  cyanotic  and  gasping.      On  aspirating 


712  PEDIATRICS. 

the  chest  and  removing  a  large  quantity  of  fluid,  the  heart  reassumed  its  normal  posi- 
tion under  the  sternum.  On  the  following  night  the  boy  died  suddenly,  the  fluid 
having  rapidly  reaccumulated  and  again  displaced  the  heart. 

Cases  of  this  kind  should  warn  us  that  a  pleuritic  exudation  of  any 
extent  in  a  young  child  should  be  watched  carefully,  and  that  aspiration 
should  be  performed  when  there  is  indication  of  an  increase  in  the  intra- 
thoracic pressure. 

AVhen  the  pleurisy  is  secondary  to  other  diseases,  such  as  rheumatism 
and  scarlet  fever,  the  prognosis  is  not  so  favorable ;  the  fluid  is  not  apt  to 
be  absorbed  so  readily,  and  is  more  likely  to  become  purulent.  The 
prognosis  is  also  rendered  more  unfavorable  in  these  cases  by  the  pro- 
longed pressure  upon  the  lung,  with  its  corresponding  ill  effects  upon  the 
general  condition  of  the  child.  The  dangers  which  arise  from  the  de- 
velopment of  tuberculosis  must  also  be  borne  in  mind. 

Treatment. — The  treatment  of  acute  pleurisy  during  the  early  days  of 
the  attack,  before  an  exudation  of  any  considerable  extent  has  appeared, 
should  be  directed  to  the  relief  of  the  pain  by  a  flannel  bandage  closely 
applied  to  the  thorax,  so  as  to  allow  the  ribs  to  move  as  little  as  possible 
in  respiration.  Sometimes  an  occasional  dose  of  tinctura  opii  campho- 
rata  will  also  be  needed  to  make  the  child  comfortable.  After  the  fluid 
has  increased,  the  child  should,  if  possible,  be  kept  in  bed.  There  are 
some  cases,  however,  in  which  a  child  with  considerable  exudation  in  its 
pleura  will  feel  well  and  bright,  and  will  play  about  its  nursery  without 
showing  any  especial  symptoms  of  discomfort.  We  have  met  with  in- 
stances of  this  kind  where,  except  for  pallor  and  a  poor  appetite,  the  child 
seemed  bright  and  active,  and  yet  had  a  pleuritic  exudation  large  enough 
to  displace  the  heart. 

The  child  should  be  examuied  each  day  in  reference  to  an  increase  in 
the  quantity  of  fluid  and  to  a  displacement  of  the  heart.  If  neither  oc- 
curs, and  if  the  respiration  and  circulation  show  no  evidence  of  disturbance, 
an  expectant  treatment  is  all  that  is  required.  If,  on  the  contrary,  the 
--fluid  is  increasing  and  the  heart  is  displaced  to  any  considerable  degree, 
or  if  absorption  of  the  fluid  is  delayed  for  two  or  three  weeks,  the  chest 
should  be  aspirated.  The  point  of  aspiration  should  usually  be  in  the 
fourth  or  fifth  interspace  in  the  midaxillary  or  posterior  axillary  line, 
but  in  deciding  where  to  enter  we  should  always  be  guided  by  the  indi- 
cations given  by  the  physical  signs.  A  bacteriological  examination  of  the 
fluid  removed  should  then  be  made,  to  determine  which  form  of  organism 
is  present  in  the  exudate.  If  one  of  the  more  benign  forms  of  bacteria  is 
present,  such  as  the  pneumococcus,  or  if  the  fluid  is  found  to  be  serous, 
no  further  treatment  will  be  required,  unless  there  be  a  reaccumulation 
of  the  fluid,  in  which  case  a  second  aspiration  will  be  indicated.  If,  how- 
ever, streptococci  are  found  in  the  exudate,  the  case  must  be  watched 
very  carefully,  as  it  is  more  likely  to  become  purulent  and  to  need  radical 
surgical  treatment. 


DISEASES    OF    THE    PLEURA.  713 

As  the  unfavorable  symptoms  in  a  pleuritic  effusion  arise  mostly  from 
intra-thoracic  pressure,  relief  from  the  pressure  by  aspiration  is  indicated 
rather  than  by  the  use  of  drugs,  which  cannot  be  depended  upon. 

Acute  Pleurisy  with  Purulent  Exudation. — Empyema. — In  the 
first  three  or  four  years  of  life  purulent  exudations  into  the  pleura  are 
much  more  common  than  serous  or  sero-fibrinous  exudations.  Nearly 
all  the  cases  which  are  secondary  to  lobar  or  broncho-pneumonia,  repre- 
senting the  largest  group  in  children,  are  caused  by  the  pneumococcus. 
The  presence  of  other  organisms  has  already  been  referred  to. 

Pathological  Anatomy. — The  inflammatory  process  begins  with  an  ex- 
udation of  fibrin  upon  the  surface  of  the  pleura,  accompanied  by  an 
excessive  migration  of  leucocytes  and  a  rapid  accumulation  of  pus.  The 
exudation  may  occasionally  be  sero-fibrinous  at  first  and  subsequently 
become  purulent.  In  cases  of  streptococcus  and  staphylococcus  infections, 
the  inflammation  may  be  purulent  from  the  beginning,  but  the  pus  is  not 
so  thick  and  contains  less  fibrin  than  in  pneumococcus  infections.  The 
pus  may  be  encysted,  but  this  rarely  occurs  in  an  empyema  following 
pneumonia. 

When  no  bacteria  are  found  in  the  fluid,  Avhen  there  is  no  history  of  a 
preceding  acute  pneumonia  or  a  neoplasm  of  any  kind,  when  there  is  little 
tendency  to  absorption  of  the  exudate,  and  when  the  exudate  is  found  to 
contain  blood,  the  signs  point  strongly  towards  a  tubercular  origin. 

Symptoms. — The  disease  when  primar}^  may  be  acute  in  its  onset,  and 
may  simulate  closely  the  initial  stage  of  lobar  pneumonia.  When  second- 
ary to  pneumonia  or  some  other  acute  infectious  disease  it  is  slow  and 
somewhat  insidious  in  its  development.  The  pulse  and  respirations  may 
be  increased,  but  after  the  early  days  of  the  disease  they  are  often  very 
little  raised.  There  is  nothing  characteristic  in  the  temperature  of  an  em- 
pyema, and  the  diagnosis  usually  can  be  made  only  from  the  knowledge 
that  the  younger  the  individual  the  more  likely  is  pus  to  be  present. 
Cachexia,  ansemia,  and  prostration  soon  become  prominent.  A  pro- 
nounced leucocytosis  is  present  from  the  onset  and  is  the  most  important 
symptom  in  the  differential  diagnosis  from  a  purely  sero-fibrinous  exuda- 
tion, which  rarely  shows  more  than  a  moderate  increase  m  the  white 
cells.  Leucocytosis  may  at  times  be  absent  when  aspiration  shows  pus 
to  be  present,  but  this  is  unusual  and  may  be  only  temporary. 

The  physical  signs  are  the  same  as  m  sero-fibrinous  exudations  and 
have  been  descrilDed  on  page  709. 

The  absorption  of  a  purulent  exudate  without  surgical  interference  is 
very  rare.  We  have  occasionally  met  with  cases  in  Avhicli  one  or  two 
aspirations  were  all  that  were  necessary  and  in  which  complete  absorp- 
tion seemingly  took  place. 

When  cases  of  empyema  are  left  untreated,  a  spontaneous  opening 
usually  takes  place  through  some  portion  of  the  thoracic  walls,  but  the 
exudate  may  also  find  its  exit  through  the  lungs  by  opening  into  one  of 


714  PEDIATRICS. 

the  bronchi  or  perforating  in  other  directions.  We  have  met  ^vith  cases 
in  Avhich  the  diaphragm  was  perforated  and  the  point  of  exit  of  the  pus 
was  in  the  region  of  the  umbilicus.  When  perforation  does  not  occur, 
the  pus  is  partially  absorbed,  adhesions  are  formed,  and  sometimes  great 
deformity  of  the  chest  follows,  which  may  result  in  a  marked  degree  of 
lateral  curvature  of  the  spine  as  well  as  in  great  contraction  of  the  chest. 

Diagnosis. — The  diagnosis  of  empyema  rests  upon  the  signs  of  fluid 
in  the  plem-al  cavity  associated  with  a  pronounced  leucocytosis,  but  it 
cannot  be  made  definitely  without  the  aid  of  the  aspirator.  In  all  doubtful 
cases  the  aspirator  should  be  freely  used,  for  the  consequences  of  a 
neglected  empyema  are  very  serious. 

The  differential  diagnosis  of  empyema  is  to  be  made  from  a  number 
of  difierent  lesions. 

From  Pneumonia. — The  conditions  wliich  are  most  likely  to  be  con- 
founded with  a  pleural  exudation  are  acute  and  unresolved  pneumonias. 
The  difficulty  arises  from  the  frequency  of  bronchial  breathing  and  bron- 
chophony and  normal  tactile  fremitus  over  a  pleural  exudation  in  early 
life.  When  the  physical  signs  are  those  both  of  fluid  and  of  consolida- 
tion, the  diagnosis  must  rest  upon  the  results  of  exploratory  aspiration. 
It  is  to  be  bonie  in  mind,  however,  that  aspiration  frequently  yields  a 
negative  result  even  when  fluid  is  present,  and  several  punctures  may 
be  necessary  before  the  diagnosis  can  be  settled.  The  possibility  of 
pneumonia  and  pleurisy  vd\h  exudation  being  combined  should  not  be 
forgotten  m  making  the  differential  diagnosis. 

From  Atelectasis. — A  smiple  broncliitis  in  children  may  cause  an  occlu- 
sion of  the  bronchi  and  produce  atelectasis  of  the  lungs,  the  signs  of 
which  may  simulate  closely  a  small  effusion.  Coughing  and  deep  kispira- 
tion  A\ill,  however,  often  remove  the  mucous  plugs  and  allow  the  air  to 
enter,  so  that  the  condition  is  readily  determined.  If  the  atelectasis  per- 
sists.'the  signs  may  surest  an  encapsulated  empyema,  and  aspiration  must 
be  resorted  to. 

From  Sero-Fibrinous  Exudations. — The  diagnosis  from  sero-fibrinous 
exudations  is  very  difficult,  but  the  younger  the  individual  the  more  likely 
is  the  fluid  to  be  purulent.  After  the  first  week  or  ten  days  of  the  dis- 
ease, however,  when  the  fluid  is  purulent,  the  usual  signs  of  absorption 
which  so  commonly  occur  in  a  serous  exudation  are  not  ordinarily  found, 
and  aspiration  of  the  pleural  cavity  \\\)l\  then  determine  which  form  of  the 
disease  is  present.     Marked  leucoc^iiosis  favors  the  diagnosis  of  empyema. 

From  Chronic  Adhesive  Pleurisy. — The  signs  of  chronic  adhesive 
pleurisy  may  exactly  resemble  those  of  fluid.  If  the  diagnosis  is  doubt- 
ful aspiration  will  make  it  clear. 

Prognosis. — The  prognosis  in  empyema  is  good  if  the  diagnosis  is 
made  early,  if  the  pneumococcus  is  the  cause,  and  if  the  case  is  properly 
treated.  If  the  infection  is  from  the  streptococcus  pyogenes  or  the  tubercle 
bacillus  the  prognosis  is  \ery  unfavorable.     If  the  pus  has  been  allowed 


DISEASES   OF   THE  PLEURA.  715 

to  remain  in  the  chest  for  a  lo:ig  period,  the  chances  of  recovery  are  pro- 
portionately dirainislied.  Spontaneous  recovery  rarely  occurs.  In  infants 
under  one  year  the  mortality  is  usually  much  higher  than  in  later  periods, 
especially  in  hospital  practi&e. 

Treatment. — The  treatment  of  empyema  is  essentially  surgical,  and  we 
shall  not  enter  into  its  details.  After  the  first  aspiration,  if  absorption 
does  not  occur  within  a  week  and  if  the  infection  is  due  to  the  pneu- 
mococcus,  it  is  well  to  wait  a  week  before  deciding  on  a  second  aspiration 
or  operation.  If  one  of  the  more  virulent  forms  of  bacteria  is  found 
in  the  exudate,  a  radical  operation  is  the  best  method  of  treatment  and 
should  be  performed  at  once.  Sometimes  one  aspiration  of  the  pus  will 
be  followed  by  permanent  and  entire  recovery.  This,  probably,  only 
occurs  in  infections  due  to  the  pneumococcus,  and  we  have  seen  such  a  case 
in  an  infant  seven  weeks  old.  We  have  also  seen  recovery  follow  after  two 
and  even  three  aspirations.  The  pleural  cavity  should  be  thoroughly 
drained  by  means  of  drainage-tubes.  In  many  cases,  especially  in  chil- 
dren over  two  or  three  years  of  age,  resection  of  one  or  two  ribs  gives  the 
best  results.  Although  in  some  cases  a  rapid  cure  in  two  or  three  weeks 
follows  the  operation,  yet  the  recovery  is  often  prolonged  for  many 
months,  even  when  strict  antiseptic  precautions  have  been  taken  at  the 
time  of  the  operation. 

The  following  cases  illustrate  pleurisy  with  sero-fibrinous  exudation : 

A  girl,  eleven  years  old,  was  attacked  with  a  chill  followed  by  vomiting  and  a 
short,  dry  cough.  Later  she  complained  of  pain  in  the  lower  part  of  the  right  chest. 
She  was  feverish,  lost  in  Aveight  and  in  appetite,  and  her  respirations  were  painful. 
She  lay  most  comfortably  on  her  back  and  on  her  left  side.  A  pleuritic  friction-rub 
was  heard  in  the  right  axillary  region.  Her  lips  and  cheeks  were  slightly  cyanotic. 
Her  tongue  was  somewhat  coated.  The  alae  nasi  were  working  and  orthopnoea  was 
marked.  The  percussion  and  auscultation  of  the  left  lung  showed  nothing  abnormal. 
The  resonance  was  fair  over  the  upper  part  of  the  right  front  and  back.  There  was 
flatness  from  about  the  fifth  dorsal  vertebra  in  the  right  back  to  the  base  of  the  lung. 
The  flatness  extended  into  the  axillary  region,  where  it  reached  its  highest  point,  and 
then  gradually  descended  to  the  right  parasternal  line  on  a  level  with  the  fourth  costal 
cartilage.  Over  this  area  of  flatness  respiration  was  markedly  diminished.  No  friction- 
rub  was  heard.  The  vocal  and  the  tactile  fremitus  were  diminished.  The  impulse  of 
the  heart  was  found  in  the  fourth  interspace,  1  cm.  (|  inch)  to  the  left  of  the  mam- 
millary  line.  The  heart-sounds  were  normal.  There  was  no  displacement  of  the  liver. 
An  examination  of  the  urine  showed  it  to  be  acid,  to  have  a  specific  gravity  of  1022, 
to  be  of  normal  color,  and  to  contain  no  albumin.  The  chlorides  were  normal.  The 
temperature  was  38.3°  to  40°  C.  (103°  to  104°  F.)  for  the  first  two  days  and  then 
gradually  declined  to  normal  in  the  course  of  three  weeks.  The  pulse  and  respirations 
were  irregular,  the  former  ranging  between  80  and  120,  and  the  latter  between  25  and 
50.  The  physical  signs  were  those  of  a  pleuritic  effusion  of  the  right  side  with  dis- 
placement of  the  heart  to  the  left. 

The  area  of  flatness  gradually  decreased,  and  an  exploratory  aspiration  showed 
the  fluid  to  be  serous.  Nine  weeks  from  the  beginning  of  the  attack,  the  dulness  on 
percussion  gradually  disappeared,  auscultation  showed  the  respiration  to  be  normal, 
and  the  heart  resumed  its  normal  position. 


716  PEDIATRICS. 

In  another  case  of  serous  effusion  in  tlie  pleura,  the  temperature  ranged  between 
37.2°  and  38.8°  C.  (99°  and  102°  F.)  for  three  weeks  and  suddenly  dropped  to  normal. 
In  the  beginning  165  c.c.  {oh  ounces)  of  fluid  were  withdrawn  troni  the  chest.  The 
fluid  reaccumulated,  so  that  absolute  dulness  was  found  over  the  whole  right  side  of 
the  chest  in  front  and  behind,  but  aspiration  did  not  have  to  be  resorted  to  again,  and 
complete  absorption  took  place  thirty  days  from  the  beginning  of  the  attack. 

Another  case  wliich  illustrates  the  difficulty  iii  diagnosticating  a  purulent 
effusion  in  the  pleura  in  the  early  days  of  the  disease  is  the  following : 

A  girl,  four  years  old,  was  suddenly  attacked  with  cough,  and  pain  in  the  right 
side.  The  temperature  was  40.5°  C.  (105°  F.).  The  respirations  were  quickened, 
and  the  pulse  was  rapid.  Nothing  abnormal  was  detected  on  physical  examination. 
On  the  following  day  the  general  symptoms  disappeared,  and  the  temperature  fell  to 
88.8°  C.  (102°  F.).  In  another  day  the  temperature  fell  to  37°  C.  (98.6°  F.),  and  the 
child  seemed  bright  and  well.  On  the  following  day,  however,  the  temperature  rose 
to  40°  C.  (104°  F.),  flatness  and  the  other  signs  of  fluid  were  detected  in  the  right  axillary 
region,  and  an  exploratory  aspiration  showed  the  presence  of  pus. 

CHRONIC  PLEURISY. 

Chronic  pleurisy  results  from  previous  attacks  of  acute  inflammations 
of  the  pleura,  either  with  or  without  the  formation  of  fluid.  Tlie  result 
is  essentially  the  same,  differing  chiefly  in  degree.  The  lesions  are  repre- 
sented by  adhesions  between  the  thickened  layers  of  parietal  and  visceral 
pleura.  Large  or  small  areas  of  the  cavity  may  thus  be  obliterated.  The 
physical  signs  are  represented  chiefly  by  dulness  and  diminution  in  the 
intensity  of  the  breathmg,  voice-sounds,  and  tactile  fremitus.  Litten's 
phenomenon  is  absent.  On  the  other  hand,  adhesions  are  often  found  at 
the  autopsy,  where  during  life  both  lungs  seemed  perfectly  normal.  The 
diagnosis  is  aided  by  the  use  of  an  aspiratmg  needle,  by  wliich  we  can 
often  detemime  by  the  sense  of  touch  whether  the  needle  is  in  a  thick- 
ened pleura,  the  lung,  or  a  free  cavity.  If  the  adhesions  are  extensive, 
retraction  of  the  chest  "^^-ith  certain  compensatory  changes  occur  as  illus- 
trated in  the  following  case. 

A  little  girl,  three  years  oldy  had  an  attack  two  years  previously  of  some  pulmo- 
nary disease  accompanied  by  fever.  From  that  time  until  she  was  first  seen  she  Avas 
delicate  and  coughed  a  great  deal.  Her  cough  had  increased,  but  she  did  not  lose  in 
weight  nor  have  any  other  abnormal  symptoms.  She  was  pale,  and  the  cervical. 
axillarj%  and  inguinal  glands  were  enlarged.  Her  fingers  were  markedly  clubbed. 
She  showed  a  peculiar  lateral  curvature  of  the  spine,  which  could  not  be  made  to  dis- 
appear by  traction.  The  right  side  of  the  thorax  expanded  normally,  the  left  side 
scarcely  at  all.  There  were  hyperresonance,  no  rales,  and  compensatory  respiration 
over  the  right  lung.  The  left  lung  was  apparently  atelectatic  and  showed  dulness 
eveiywhere  except  in  a  small  triangular  area  at  the  inferior  angle  of  the  scapula.  This 
deformity  of  the  thorax  was  probably  the  result  of  an  empyema  which  occurred  when 
she  was  one  year  old  and  was  not  properly  treated. 

Treatment. — The  treatment  consists  entirely  of  general  hygiene  and 
systematic  exercises  of  the  chest. 


PLATE   XIIT. 


Case  of  Hydropneumothorax,  in  a  boy  of  7  years,  with  the  patient  in  the  upright  position,  showing 
the  shadow  of  the  level  of  the  effusion  on  the  left  side,  as  well  as  the  marked  displacement  of  the  cardiac 
shadow  to  the  right. 


PLATE  XIV. 


Case  of  Hydropneumothorax,  in  a  boy  of  7  years,  with  the  patient  in  the  dorsal  decubitus.  Radio- 
graph shows  the  shadow  cast  by  the  effusion,  occupying  nearly  all  of  the  left  chest,  with  the  exception 
of  the  extreme  apex.    Cardiac  shadow  seen  somewhat  displaced  to  the  right. 


DISEASES   OF   THE   PLEURA.  717 

HYDROTHORAX. 

Hydrothorax  is  a  non-inflammatory  affection,  characterized  by  the 
transudation  of  a  simple  fluid  into  the  pleural  cavities.  It  is  a  rare  affec- 
tion in  children.  The  effusion  is  the  result  of  mechanical  obstruction  to 
the  flow  of  the  subpleural  blood  and  lymph.  The  principal  causes  for 
this  obstruction  are  found  in  diseases  of  the  heart  and  kidneys.  The  fluid 
is  generally  bilateral ;  in  some  cardiac  cases  it  may  be  unilateral.  It  is 
apt  to  he  greater  in  amount  on  one  side  than  on  the  other. 

The  transudation  is  watery  in  character,  of  low  speciflc  gravity,  under 
1015,  and  contains  less  albumin  than  inflammatory  exudations,  generally 
from  one  to  two  per  cent.  It  does  not  coagulate  spontaneously  unless 
complicated  with  the  exudation  of  an  inflamed  pleura.  A  few  leucocytes, 
red  blood-corpuscles,  and  endothelial  cells  may  be  found  Avhen  the  sedi- 
ment obtained  by  the  centrifuge  is  examined  microscopically. 

Symptoms. — The  symptoms  are  in  most  cases  simply  those  of  the  con- 
dition to  which  the  hydrothorax  is  secondary.  If  the  fluid  is  excessive 
there  is  a  sense  of  constriction  beneath  the  sternum,  dyspnoea,  and  short, 
rapid  respirations,  weak  pulse,  and  sometimes  cyanosis.  Any  of  these 
symptoms  may  be  due  to  the  primary  disease  alone,  and  it  is  therefore 
of  much  importance  to  watch  the  lungs  carefully  in  all  advanced  and 
serious  cases  of  cardiac  and  renal  disease  associated  with  dropsy. 

The  physical  signs  are  tliose  of  pleurisy  with  exudation.  There  is 
no  friction-rub,  as  the  pleurae  are  not  inflamed,  and  the  fluid  shifts  more 
readily  on  change  in  position,  because  of  the  absence  of  inflammatory 
adhesions. 

Diagnosis. — The  diagnosis  can  be  made  from  inflammatory  exudations 
by  the  chemical  examination  of  the  fluid  obtained  by  aspiration. 

Treatment. — The  treatment  is  that  of  the  primary  disease  to  which 
the  hydrothorax  is  secondary.  If  the  symptoms  of  pressure  are  serious, 
repeated  aspiration  is  generally  necessary. 

PNEUMOTHORAX. 

Pneumothorax,  or  air  in  the  pleural  cavity,  rarely  occurs  alone.  It  is 
generally  associated  with  serous  or  sero-fibrinous  fluid,  and  is  then  called 
hydropneumothorax  ;  or  with  pus,  when  we  speak  of  it  as  pyopneumothorax. 

Etiology. — Air  may  enter  the  pleural  cavity  from  penetrating  wounds 
from  without,  such  as  may  result  from  aspiration.  The  most  frequent 
cause,  however,  is  due  to  perforation  of  the  visceral  pleura  in  the  course 
of  pulmonary  tuberculosis,  gangrene,  or  abscess.  Nine-tenths  of  the 
cases,  according  to  Fraentzel,  are  due  to  pulmonary  tuberculosis.  The 
condition  is  of  rare  occurrence  in  children. 

Pathological  Anatomy. — As  a  result  of  the  entrance  of  air  into  the 
pleural  cavity,  the  lung  collapses  and  is  withdrawn  into  the  upper  and  pos- 
terior part  of  the  pleural  cavity.  The  amount  of  retraction  depends  upon 
the  extent  of  the  pleural  adhesions  or  consolidation  present.    The  entrance 


718  PEDIATRICS. 

of  air  is  generally  accompanied  by  micro-organisms,  and  by  the  conditions 
which  follow  a  sero-fibrinous  or  purulent  inflammation  of  the  pleura. 

Symptoms. — The  onset  when  sudden  is  characterized  by  severe  pain  in 
the  side,  dyspnoea,  a  weak,  rapid  pulse,  and  great  prostration.  Some- 
times the  pneumothorax  develops  insidiously  without  giving  rise  to  these 
symptoms  of  distress.     The  physical  signs  are  distinctive. 

Inspection. — Respiration  is  diminished  on  the  affected  side  and 
Litten's  sign  is  absent.  The  heart  may  be  displaced  in  the  same  way 
as  by  a  pleuritic  effusion. 

Palpation. — Tactile  fremitus  is  absent  over  the  lower  part  of  the 
chest,  but  may  be  normal  or  even  increased  at  the  upper  posterior  por- 
tion over  the  retracted  lung.  The  liver  is  generally  displaced  if  the 
pneumothorax  is  on  the  right  side.  The  apex  of  the  heart  will  also  be 
found  to  be  displaced  as  in  effusions. 

Percussion. — Tympanitic  resonance  is  pronounced  throughout  the 
affected  side,  and  may  be  so  marked  as  to  mask  the  presence  of  small 
effusions.  When  the  air  within  the  pleural  cavity  is  very  tense,  the  per- 
cussion-note may  be  muffled,  simulating  dulness. 

Auscultation.— The  respirations  and  voice-sounds  are  very  faintly 
heard  or  are  absent  in  the  lower  portions  of  the  chest,  whereas  at  the  top 
a  faint  amphoric  or  metallic  breathing  may  be  heard.  If  one  coin  is  tapped 
against  another  coin  placed  on  the  back  over  the  tympanitic  area,  the 
metallic  echo  is  readily  transmitted  to  the  stethoscope  on  the  front  of  the 
chest,  and  is  quite  characteristic.  When  the  pneumothorax  is  accom- 
panied by  fluid,  as  is  generally  the  case,  the  signs  of  pneumothorax  and 
fluid  are  combined  and  vary  in  their  character  according  to  the  relative 
predominance  of  fluid  or  air.  The  sound  of  splashing  obtained  by  suc- 
cussion  is  very  distinctive  of  air  and  fluid,  but  must  not  be  confused  with 
similar  sounds  transmitted  from  the  stomach.  The  difference  can  be 
made  out  by  attention  to  the  position  of  the  intensity  of  the  sound. 

Diagnosis. — Only  when  the  air  is  very  tense,  and  gives  a  muffled  or 
dull  note,  will  the  physical  signs  resemble  those  of  fluid.  If  the  diagnosis 
is  doubtful,  aspiration  will  make  it  clear.  Very  large  tubercular  cavities 
may  give  rise  to  the  signs  of  pneumothorax,  but  they  are  rare  in  children, 
and  even  when  present  are  not  associated  with  succussion  or  displace- 
ment of  organs. 

Pneumothorax  and  emphysema  resemble  each  other  in  the  signs  of 
feeble  breathing  and  hyperresonance,  but  emphysema  is  almost  always 
bilateral, "  with  the  coarse  moist  rales  of  an  associated  bronchitis,  and  does 
not  displace  the  heart  or  liver,  although  it  may  alter  the  cardiac  and 
hepatic  areas  of  dulness. 

Prognosis. — The  prognosis  of  pneumothorax  depends  largely  upon 
the  primary  condition  to  which  it  is  secondary. 

Treatment. — The  treatment  is  essentially  the  same  as  that  of  pleurisy 
with  effusion. 


DIVISION    XL 

DISEASES  OF  THE  HEART  AND  PERICARDIUM. 


DISEASES  OF  THE  HEART. 

Cardiac  disease  in  infancy  and  early  childhood  may  be  divided  into 
congenital  or  acquired,  developmental  or  inflammatory,  organic  or  func- 
tional, acute  or  chronic.  In  this  early  period  of  life  cardiac  disease  has 
certain  characteristics  in  which  it  differs  essentially  from  those  which  are 
met  "sdth  in  later  life.  One  of  these  characteristics  is  that  there  is  a  more 
decided  tendency  to  recovery  than  at  a  later  period.  Another  is  that, 
owing  to  the  undeveloped  condition  of  the  infant  and  young  child,  inter- 
ference with  the  growth  of  other  organs  and  parts  of  the  body  may  more 
easily  result  from  diseases  connected  with  the  circulation  than  is  possD^le 
in  the  case  of  the  fully  developed  adult.  Thus,  there  are  certain  ana- 
tomical facts  connected  with  the  ossification  of  the  sternum  which  be- 
come of  great  importance  in  connection  with  cardiac  disease.  Deformi- 
ties of  the  thorax  may  result  from  the  continued  pressure  of  the  enlarged 
heart  on  the  soft  and  pliant  sternum  -and  costal  cartilages  of  the  young 
subject.  These  deformities  do  not  arise  merely  when  the  individual  is 
rhachitic,  but  may  also  depend  upon  the  stage  of  development  at  which 
the  cardiac  disease  begins.  The  deformity  is  more  or  less  pronounced  in 
inverse  ratio  to  the  age  and  in  direct  ratio  to  the  time  during  wliich  the 
cardiac  disease  has  existed.  The  shape  and  extent  of  the  deformity  are 
also  dependent  upon  the  degree  of  ossification  wliich  has  taken  place  in 
the  sternum. 

In  young  infants,  in  whom  the  entire  sternum  is  in  a  cartilagmous  con- 
dition, the  intra-thoracic  pressure  from  an  enlarged  heart  may  cause  a 
bulging  of  the  whole  front  of  the  thorax.  This  may  occur  during  the  first 
year,  and  even  up  to  the  third  year.  As  the  child  grows  older,  the  manu- 
brium and  the  second  piece  of  the  sternum  become  ossified  and  offer  more 
resistance,  while  the  thuTJ  piece  of  the  sternum,  still  remaining  in  a  semi- 
cartilaginous  condition,  may  be  tilted.  This  latter  displacement  may 
occur  in  children  in  whom  the  cardiac  disease  has  not  developed  until  the 
fourth,  fifth,  or  sixth  year.  We  have  had  under  our  care  a  child  seven 
years  old  who  at  the  age  of  five  years  had  rheumatic  fever,  and  who  pre- 
sented this  displacement  of  the  third  piece  of  the  sternum,     Xo  other 

719 


720  PEDIATRICS. 

signs  of  rhachitis  were  detected.  The  middle  period  of  childhood  is  also 
a  peculiarly  unfortunate  one  for  the  occurrence  of  cardiac  disease,  because 
the  heart  grows  so.  rapidly  at  this  period  that  it  requires  a  proportionately 
greater  amount  of  intra-thoracic  space  for  the  normal  performance  of  its 
function  than  it  does  later. 

In  addition  to  the  injury  which  may  be  done  to  the  thoracic  walls  by 
an  enlarged  heart,  we  must  consider  the  interference  with  the  normal 
uniform  expansion  so  necessary  for  the  growing  pulmonary  tissue  and 
the  consequent  loss  of  the  elasticity  which  plays  so  prominent  a  part  in 
the  establishment  of  the  equipoise  which  should  exist  in  a  perfected 
respiratory  apparatus. 

The  occurrence  of  diseases  of  the  blood-vessels  is  rare  in  infancy  and 
early  childhood  in  comparison  with  later  life.  Aneurism  is  rare.  A 
narrowing  of  the  isthmus  aortce  is  more  common,  and  is  one  of  the  most 
marked  of  the  congenital  defects  of  the  blood-vessels.  It  may  result  in 
increased  blood-tension,  followed  by  hypertrophy  of  the  left  ventricle 
and  subsequent  dilatation.  Sometimes  there  is  an  absence  of  the  isthmus 
aortce  during  foetal  life.  The  compensation  for  this  defect  takes  place  by 
an  increased  action  of  the  left  ventricle  and  the  establishment  of  a  col- 
lateral circulation  between  the  subclavian  artery  and  the  thoracic  and  the 
abdominal  aorta.  These  malformations  exert  in  varying  degrees  an  in- 
fluence on  the  heart,  as  the  infant  grows  older,  from  increased  blood- 
pressure. 

CONGENITAL  DISEASES  OF  THE  HEART. 

Congenital  diseases  of  the  heart  are  somewhat  obscure  in  their 
etiology,  but  usually  result  either  from  an  interference  with  the  normal 
development  of  the  organ  or  from  endocarditis,  or  from  a  combination 

,  of  both.  The  parts  of  the  foetal  circulation  at  birth  which  are  of  most 
importance  in  reference  to  diseased  conditions  of  the  heart  and  great  blood- 
vessels are  the  foramen  ovale  and  the  ductus  arteriosus.     When  these 

~  remains  of  the  foetal  circulation,  which  are  normal  during  intra-uterine 
life  and  for  a  short  period  afterwards,  continue  as  the  infant  grows  older, 
they  become  abnormal  and  interfere  with  the  equilibrium  of  the  circu- 
lation. 

When  the  development  of  the  heart  has  been  interfered  with  in  intra- 
uterine life,  there  results  another  set  of  malformations,  the  chief  of  which 
are  an  open  ventricular  septum,  a  transposition  of  the  great  vessels  con- 
nected Avith  the  heart,  and  various  malformations  of  the  valves,  such  as 
atresia  of  the  orifice,  absence  of  one  or  more  cusps,  or  supernumerary 
segments.  There  may  also  be  absence  of  one  of  the  large  vessels. 
When,  again,  an  inflammatory  condition  has  taken  place  in  intra-uterine 
life  (foetal  endocarditis),  various  other  morbid  conditions  result,  usually 
located  in  the  right  side  of  the  heart,  the  most  common  of  which  are 


CONGENITAL   DISEASES   OF   THE   HEART.  721 

connected  with  the  puhiionary  artery,  causing  stenosis  or  atresia,  a  nar- 
rowing of  the  conus  arteriosus,  and  various  malformations  of  the  tricuspid 
valve  and  other  orifices  of  the  heart.  These  inflammatory  lesions  of  the 
valves  result  in  dilatation  and  hypertrophy  of  the  heart  and  prevent  its 
normal  development  by  keeping  open,  for  the  purpose  of  compensation, 
the  foramen  ovale,  the  ventricular  septum,  and  the  ductus  arteriosus. 
The  valvular  lesions  vary  greatly  in  their  extent  and  pathology. 

It  is  sometimes  very  difficult  to  distinguish  between  the  lesions  re- 
sulting from  foetal  endocarditis  and  errors  of  development.  The  nodules 
of  Albini  and  the  small  hemorrhages  which  are  so  commonly  found 
on  the  cardiac  valves  in  children,  must  not  be  mistaken  for  endocar- 
ditis. The  form  of  inflammation  of  the  endocardium  which  occurs  in 
intra-uterine  life  is  the  chronic  or  sclerotic  variety.  Verrucose  endo- 
carditis is  rare. 

A  deficient  filling  of  the  left  side  of  the  heart  in  early  life,  such  as 
occurs  in  cases  of  atelectasis,  foetal  pneumonia,  or  foetal  endocarditis, 
especially  when  stenosis  of  the  pulmonary  artery  has  resulted,  may  delay 
the  closure  of  the  foramen  ovale  and  of  the  ductus  arteriosus,  which 
under  these  circumstances  act  as  safety-valves.  This  is  true  also  of  the 
delay  in  the  closing  of  the  intra-ventricular  septum,  which  is  often  of 
great  aid  in  preser\'ing  the  equilibrium  of  the  circulation.  The  most 
common  congenital  cardiac  lesions  are  an  aff'ection  of  the  pulmonary 
artery,  an  open  foramen  ovale,  an  open  ventricular  septum,  and  an  open 
ductus  ateriosus. 

Transpositions  of  the  aorta  and  pulmonary  artery  are  very  com- 
monly met  with  in  connection  with  other  congenital  defects,  such  as  spina 
bifida  or  hydrocephalus,  but  may  occur  in  infants  who  are  otherwise 
normally  developed.  In  these  cases  the  duration  of  life  is  almost  in- 
variably short. 

Although  these  various  abnormal  conditions  may  be  found  alone,  yet 
they  generally  occur  in  combination  with  each  other,  and  all  kinds  of 
transpositions  and  malformations  of  the  vessels  are  at  times  met  with. 

There  are  various  other  malformations  of  the  heart  which  occur  at  an 
early  period  of  foetal  development,  and  which  are  of  pathological  rather 
than  clinical  interest.  Of  these  can  be  mentioned  cases  in  which  there  are 
one  auricle  and  one  ventricle  {cor  biloculare),  or  one  ventricle  and  two  auri- 
cles (cor  triloculare'),  as  well  as  a  case  which  has  come  under  my  notice,  in 
which  the  heart  had  a  double  apex,  the  right  apex  lying  in  the  fourth 
interspace  to  the  right  of  the  sternum,  and  the  left  apex  lying  in  the 
fourth  interspace  to  the  left  of  the  sternum.  At  times  there  may  be  a 
double  heart,  absence  of  heart  (acardia),  heart  on  the  right  side  {dextro- 
cardia), or  the  heart  may  be  in  various  parts  of  the  thorax  or  abdomen. 

General  Symptoms. — Although  in  some  cases  the  symptoms  of  con- 
genital cardiac  disease  are  very  indefinite,  and  the  disease  may  be  masked 
for  a  number  of  months,  yet  in  a  large  number  of  cases  they  soon  be^ 

46 


722  PEDIATRICS. 

come  evident.  The  typical  symptoms  of  congenital  cardiac  disease  are 
cyanosis  and  attacks  of  dyspnoea,  amounting  at  times  to  suffocation,  and 
imperfect  development.  As  the  disease  progresses,  the  fingers  and  toes 
often  become  club-shaped,  the  nails  blue,  and  the  skin  cool.  In  connection 
with  these  rational  signs  there  is  usually  an  evident  pulsation  in  the  cardiac 
region,  with  bulging  of  the  precordia.  When  the  obstruction  caused  by 
the  lesions  is  sufficient  to  produce  hypertrophy  and  dilatation  of  the 
heart,  an  increase  in  the  area  of  cardiac  dulness  is  found.  Diffuse  cardiac 
murmurs  are  heard  often  over  the  whole  chest,  but  usually  have  their 
maximum  intensity  towards  the  upper  part  of  the  sternum,  are  commonly 
systoUc  in  time,  and  in  some  cases  are  accompanied  by  a  thrill. 

The  most  common  symptom  is  cyanosis.  Cyanosis  may  arise  from 
incomplete  oxygenation  of  the  blood,  and  not  merely  from  a  mixture  of 
the  venous  and  arterial  currents.  When  cyanosis  is  present  to  any  extent 
there  is  usually  some  malformation  of  the  pulmonary  artery  or  its  valves. 
Well-marked  congenital  malformations  may  be  present  with  no  symptoms 
whatever.  There  may  be  an  entire  absence  of  cyanosis ;  there  may  be 
no  increased  area  of  dulness  and  no  murmurs;  and  we  have  met  with 
instances  in  which  the  infants  seemed  to  be  thriving,  and  showed  neither 
labored  breathing  nor  physical  signs  of  disease  up  to  within  a  few  hours 
of  death,  and  yet  a  number  of  cardiac  malformations  were  found  at  the 
autopsy.  Although,  as  a  rule,  the  symptoms  occur  at  a  very  early  period 
of  extra-uterine  life,  yet  quite  frequently  they  are  so  mild  in  character 
that  they  are  not  especially  noticed,  as  they  may  appear  only  when  the 
infant  is  much  excited  or  crying.  The  cardiac  symptoms  may  not  be 
prominent  enough  to  attract  attention  until  the  infant  is  old  enough  to 
exert  itself  sufficiently,  as  by  creeping  or  walking,  to  interfere  with  the 
equilibrium  of  its  circulation.  At  times  another  disease,  especially  bron- 
chitis or  pneumonia,  may  precipitate  the  cardiac  symptoms.  It  is  quite 
common  for  endocarditis  to  develop  in  a  heart  in  which  a  congenital 
malformation  is  present.  The  diagnosis  between  a  congenital  and  an  ac- 
quired cardiac  affection  then  becomes  necessary  and  is  accompanied  by 
many  difficulties. 

The  following  case  illustrates  how  congenital  cardiac  disease  can  be 
masked  for  a  number  of  weeks  : 

The  infant  was  apparently  healthy  at  birth,  and  a  careful  physical  examination 
showed  nothing  abnormal  in  the  thorax.  There  was  no  cynosis  noticed,  the  skin 
being  of  a  normal  color.  When  it  was  sixteen  days  old  it  refused  to  take  the  breast, 
and  in  the  afternoon  seemed  soraewhat  cold,  was  slightly  cyanotic,  and  had  a  tem- 
perature of  35.2°  C.  (95.5°  F.).  An  examination  of  the  heart  detected  nothing 
abnormal.  A  few  drops  of  brandy  were  given  to  it,  and  after  several  hours  the  skin 
became  warm,  the  respirations  normal,  and  it  took  its  food  as  usual.  Early  in  the 
following  morning  the  quickened  respiration  returned,  the  temperature  rose  to  37.7°  C. 
(100°  F.),  it  refused  to  take  its  food,  failed  rapidly,  and  died  in  the  afternoon. 

The  examination  of  the  heart  showed  a  large  open  foramen  ovale  and  an  absence 
of  the  upper  part  of  the  intra-ventricular  septum  below  the  aortic  valve.     The  be- 


CONGENITAL   DISEASES   OF   THE    HEART.  793 

ginning  of  the  aorta  for  a  distance  of  1  cm.  (|  inch)  was  dilated  into  a  spherical 
pouch,  from  which  were  given  off  (1)  the  aorta  without  any  branches  before  the  inter- 
costals,  thus  supplying  only  the  lower  part  of  the  body,  (2)  a  large  vessel  to  the  right 
lung,  and  (3)  a  large  vessel  to  the  left  lung.  From  the  upper  part  of  the  right  ven- 
tricle was  given  off  a  large  vessel  which  divided  1.4  cm.  Q-  inch)  above  the  pulmonary 
valve  into  a  large  vessel  on  the  right  side  and  two  smaller  ones  on  the  left.  The  large 
vessel  apparently  corresponded  to  the  innominate,  and  the  other  two  vessels  to  the 
subclavian  and  common  carotid  of  the  left  side.  By  these  vessels  blood  was  supplied 
to  the  head  and  upper  extremities.  There  was  no  communication  between  the  arterial 
and  pulmonary  vessels,  as  the  ductus  arteriosus  was  absent.  The  cause  of  the  dila- 
tation of  the  beginning  of  the  aorta  was  a  thickening  and  narrowing  of  the  vessel  for 
8  mm.  (}  inch)  just  beyond  the  dilatation.  The  heart  was  enlarged,  but  not  especially 
hypertrophied. 

There  was  a  general  streptococcus  invasion,  for  which  no  source  could  be  found. 
The  cord  had  come  away  at  the  usual  time  without  leaving  any  abnormal  condition  in 
the  neighborhood  of  the  umbilicus. 

General  Diagnosis. — Although  it  is  usually  possible  to  make  a  diagnosis 
of  congenital  cardiac  disease,  yet  when  we  consider  the  variety  of  lesions 
which  may  occur,  and  the  combination  of  different  lesions  wliich  may  be 
present,  with  the  same  symptoms  or  a  marked  lack  of  symptoms,  it  will 
be  understood  that  a  diagnosis  of  the  especial  lesion  is  often  impossible. 

Bearing  in  mind  the  mechanism  of  the  foetal  circulation  and  the  con- 
nection which  an  enlargement  of  the  heart  has  with  especial  lesions,  Ave 
can  sometimes  arrive  at  an  approximately  correct  diagnosis.  Too  much 
reliance,  however,  must  not  be  placed  upon  the  locality  or  sound  of  the 
cardiac  muniiurs,  as  such  murmurs  may  be  produced  by  very  trivial 
lesions,  and  may  be  absent  when  the  lesions  are  most  pronounced.  The 
following  characteristics  may,  however,  be  considered  to  represent  the 
more  common  congenital  anomalies. 

OPEN    FORAMEN    OVALE. 

One  of  the  most  common  congenital  malformations  of  the  heart  is 
represented  by  a  defect  in  development  of  the  auricular  septum  by  an 
open  foramen  ovale.  The  failure  of  the  foramen  ovale  to  close  is  usually 
caused  by  an  interference  with  the  pulmonary  circulation,  such  as  may 
occur  in  atelectasis.  Premature  closure  of  the  foramen  ovale  has  been 
met  with,  but  is  extremely  rare. 

So  long  as  the  patent  foramen  ovale  is  not  associated  with  other  de- 
fects it  does  not,  as  a  rule,  produce  a  murmur  or  give  rise  to  any  symp- 
toms. The  reason  for  this  is  supposed  to  be  that  the  blood  can  only  flow 
from  the  right  auricle  into  the  left  when  the  pressure  is  greater  in  the 
former,  and  it  is  not  greater  unless  there  is  some  obstruction  either  at  the 
tricuspid  valve  or  in  the  pulmonary  valve  or  artery,  by  which  the  flow 
of  the  blood-current  into  the  right  ventricle  is  interfered  with. 

When  symptoms  such  as  cyanosis  or  murmurs  are  met  with  in  connec- 
tion with  an  open  foramen  ovale,  they  almost  always  depend  on  asso- 
ciated lesions,  the  most  common  of  which  are  stenosis  of  the  pulmonan' 


724  PEDIATRICS.  ^ 

artery  and  a  defect  in  the  ventricular  septum.  The  prognosis  in  uncom- 
phcated  cases  of  patent  foramen  ovale  is  good,  as  the  lesion  is  one  wliich 
need  not  cause  much  embarrassment  of  the  circulation. 

DEFECT    OF    THE    VENTEICUL.AR    SEPTUM. 

A  defect  in  the  ventricular  septum  is  a  very  frequent  congenital  lesion. 
li  may  be  complete,  but  is  usually  partial,  and  is  most  common  in  the  upper 
part.  This  defect  rarely  occurs  alone,  but  is  associated  with  other  lesions, 
especially  stenosis  of  the  pulmonarj^  artery,  and  in  such  cases  acts  as  a 
safety-valve.  An  abnormal  origm  of  the  great  vessels  is  also  frequently 
found  with  this  defect.  As  the  lesion  is  so  frequently  associated  with 
other  anomalies,  there  are  no  sharjDly  marked  and  distinctive  symptoms. 
In  most  cases,  however,  a  loud  systohc  murmur  is  heard  over  the  whole 
front  of  the  chest,  with  its  maximum  intensity  hardly  ever  near  the  apex, 
and  with  a  notable  absence  of  a  palpable  thrill.  In  uncomplicated  cases 
hypertrophy  of  the  ventricles  is  not  marked. 

"When  the  right  ventricle  is  stroug  enough  to  resist  the  increased 
blood-pressure  from  the  left  ventricle,  the  circulation  is  carried  on  nor- 
mally without  compensatory  hypertrophy  and  without  cyanosis  or  dropsy. 
When,  however,  great  expiratory  efforts  occur,  as  in  bronchitis  and  per- 
tussis, or  when  the  blood-pressure  is  mcreased  from  any  other  cause, 
dilatation  of  the  right  ventricle  may  set  in  acutely  with  symptoms  of 
broken  compensation,  especially  those  of  cyanosis  and  dropsy.  These 
symptoms  may,  for  a  tune,  be  delayed  by  a  compensatory  hypertrophy 
of  the  right  ventricle. 

The  prognosis  must  necessarily  be  uncertain  and  unsatisfactory,  as  in 
so  many  instances  the  defective  septum  is  accompanied  by  other  lesions. 
In  most  instances  the  infants  cUe  early,  but  cases  have  been  reported  in 
which  they  have  lived  for  many  years. 

LESIONS    OF    THE    PUIiMONARY    ORIFICE. 

There  are  three  lesions  of  the  pulmonary  orifice  which  play  a  very 
important  role  m  congenital  cardiac  disease.  These  are  stenosis  or  atresia 
of  the  pulmonary  orifice  and  stenosis  of  the  conus  arteriosus  of  the  right 
ventricle.  These  lesions  may  occur  alone,  but  most  commonly  are  asso- 
ciated ^vith  a  defect  in  the  septa  and  with  a  patent  ductus  arteriosus. 
They  may  be  the  result  of  a  fault  in  development  or  of  a  fcetal  endocar- 
ditis. 

Pulmonary  Stenosis. — TMs  lesion  is  characterized  by  extreme  cyano- 
sis, cold,  livid  extremities,  clubbing  of  the  fingers,  rapid  respirations,  and 
a  tendency  to  dyspnoea.  The  physical,  like  the  rational,  signs  are  more 
characteristic  than  in  the  other  forms  of  cardiac  anomalies.  They  consist 
chiefly  of  a  loud  systolic  murmur  heard  most  distinctly  in  the  pulmonarj' 
region  and  transmitted  in  all  directions.  There  is,  according  to  the  extent 
of  the  stenosis,  a  weak  or  absent  pulmonic  second  sound :  if.  however, 


CONGENITAL   DISEASES   OF   THE   HEART.  725 

the  ductus  arteriosus  happens  to  be  patent  there  may  be  no  diminution 
in  the  intensity  of  the  puhnonic  second  sound.  In  some  cases  a  palpable 
systolic  thrill  may  be  felt  in  the  pulmonary  region.  In  many  cases,  how- 
ever, the  murmur  obscures  and  dominates  all  other  sounds.  Generally 
there  is  an  increased  area  of  cardiac  dulness  extending  to  the  right  of  the 
sternum  and  representing  hypertrophy  of  the  right  ventricle. 

Notwithstanding  the  apparent  gravity  of  the  lesion,  pulmonary  stenosis 
permits  the  infant  to  live,  often  for  many  years,  but  there  is  always  in  these 
cases  a  special  tendency  to  tuberculosis  and  to  pneumonia. 

Pulmonary  Atresia. — This  lesion  is  less  common  but  much  more 
serious  than  stenosis.  It  is  so  commonly  combined  with  other  anomalies, 
such  as  defects  in  the  septa  and  patent  ductus  arteriosus,  that  it  cannot  be 
said  to  have  any  distinctive  physical  signs  of  its  own,  while  its  general 
symptoms  are  the  same  as  those  of  pulmonary  stenosis. 

Stenosis  of  the  Conus  Arteriosus. — This  is  an  anomaly  of  develop- 
ment, is  usually  associated  with  other  lesions  of  the  orifice,  and  tends  to 
accentuate  the  symptoms  and  results  of  such  lesions.  Pulmonary  insuffi- 
ciency has  been  observed  in  certain  cases,  but  is  very  rare. 

PERSISTENCE    OF  THE  DUCTUS    ARTERIOSUS. 

This  lesion  when  existing  alone  may,  as  in  a  case  which  has  come 
under  my  observation,  present  no  symptoms  except  slight  and  evanescent 
cyanosis.  The  sign  which,  in  addition  to  a  light  grade  of  cyanosis  and  a 
cadaverous  color,  is  most  characteristic  of  this  condition  is  a  loud  vibra- 
tory systolic  murmur,  with  its  greatest  intensity  at  the  base  of  the  heart. 
If  the  lesion  is  unassociated  Avith  other  anomalies,  there  is  no  hyper- 
trophy of  the  ventricles,  but  if,  as  so  often  occurs,  there  is  obstruction  at 
the  pulmonary  orifice,  there  is  usually  also  hypertrophy  of  the  right 
ventricle,  and  a  diagnosis  cannot  be  made,  as  the  murmur  cannot  be  dis- 
tinguished from  that  of  pulmonary  stenosis. 

The  ductus  arteriosus  should  gradually  be  obliterated  within  the  first 
two  weeks  of  extra-uterine  life.  Interference  with  this  normal  involution 
is  not  very  uncommon,  rarely  occurs  alone,  and  is  usually  found  in  con- 
nection with  lesions  of  the  pulmonary  artery  or  narrowing  of  the  isthmus 
aortse.  Sometimes  the  process  of  obliterative  endarteritis  extends  to  the 
aorta  and  causes  stenosis  of  the  isthmus  aortse.  Again,  the  duct,  in 
closing  and  retracting,  pulls  the  aorta  and  tends  to  narrow  that  vessel,  thus 
increasing  the  arterial  tension.  During  foetal  life  stenosis  of  the  isth- 
mus aortae  does  not  produce  much  disturbance  in  cases  in  which  the 
ductus  arteriosus  can  carry  the  blood  to  the  descending  aorta.  At  birth, 
however,  in  these  cases,  unless  the  ductus  arteriosus  remains  pervious, 
serious  symptoms  arise.  If  life  is  prolonged,  hypertrophy  of  the  left  ven- 
tricle takes  place,  and  the  arterial  blood  has  to  be  conveyed  to  the  de- 
scending aorta  by  means  of  a  collateral  circulation  which  is  established 
between  the  branches  of  the  subclavian  arteries  and  the  branches  of  the 


726  PEDIATRICS. 

thoracic  and  abdominal  arteries.  Premature  closure  of  the  ductus  arterio- 
sus during  foetal  life  has  been  met  with,  but  is  a  rare  condition.  Very 
rarely  the  ductus  arteriosus  may  be  entirely  absent. 

TRANSPOSITION  OF  THE  LARGE   ARTERIES. 

A  transposition  of  the  aorta  and  pulmonary  arteries  sometimes  occurs 
v>^hen  the  former  arises  from  the  right  and  the  latter  from  the  left 
ventricle.  Both  arteries  may  arise  from  a  common  trunk,  and  a  number 
of  other  anomalies  which  are  very  rare  may  exist.  Transposition  of 
the  arteries  is  not  an  uncommon  anomaly,  but  there  are  no  symptoms  by 
which  the  condition  can  be  diagnosticated,  as  there  may  be  an  entire  ab- 
sence of  cyanosis,  cardiac  hypertrophy,  and  murmurs.  The  anomaly  is, 
however,  at  times  accompanied  by  intense  cyanosis,  asphyxia,  cool  skin 
and  extremities,  and  apathy,  but  as  it  is  always  associated  with  other  lesions, 
there  are  no  distinctive  symptoms  by  which  a  diagnosis  can  be  made. 

When  this  transposition  of  the  main  arterial  trunks  occurs  the  infant 
usually  lives  but  a  short  time. 

LESIONS  OF  THE  TRICUSPID  ORIFICE. 

Tricuspid  Stenosis. — This  lesion  is  usually  the  result  of  a  foetal 
endocarditis.  It  is  very  rare  and  is  often  associated  with  deficient  de- 
velopment of  the  right  ventricle  and  hypertrophy  and  dilatation  of  the  left 
ventricle. 

Tricuspid  Insufficiency. — This  also  is  very  rare,  and  results  in 
hypertrophy  of  the  right  ventricle  and  dilatation  of  the  right  auricle. 

Both  of  these  lesions  are  accompanied  usually  by  a  number  of  other 
anomalies,  so  that  there  are  no  distinct  symptoms  by  which  to  make  a 
diagnosis,  but,  as  a  rule,  the  cyanosis  is  pronounced,  the  heart  impulse 
is  unusually  strong,  there  are  extensive  systolic  and  diastolic  murmurs, 
thrills,  venous  pulsation  in  the  neck,  epigastric  pulsation,  and  a  tendency 
to  hemorrhage. 

~^  LESIONS  OF  THE  MITRAL  AND   AORTIC   ORIFICES. 

Although  lesions  of  the  left  side  of  the  heart  may  be  produced  by 
foetal  endocarditis,  they  are  exceedingly  rare,  in  comparison  with  lesions 
of  the  right  side  of  the  heart,  and  are  generally  associated  with  a  number 
of  other  congenital  cardiac  anomalies.  Their  symptomatic  significance  is 
the  same  as  when  they  occur  in  extra-uterine  endocarditis,  and  will  be 
described  under  acquired  diseases  of  the  heart.  It  may  be  said,  how- 
ever, that  the  signs  of  tricuspid,  mitral,  and  aortic  lesions  do  not  differ 
materially  from  those  met  with  in  adults. 

The  duration  of  life  when  the  lesions  are  at  the  aortic  orifice  is  not 
nearly  so  long  as  when  the  pulmonary  orifice  is  affected. 

Differential  Diagnosis  of  Congenital  Disease  of  the  Heart. — The 
differential  diagnosis  of  congenital  from  acquired  organic  disease,  and  of 
the  different  varieties  of  congenital  lesions,  is  exceedingly  difficult  at  times, 


CONGENITAL   DISEASES   OF   THE    HEART. 


727 


and  often  cannot  be  made.  Certain  facts,  however,  which  seem  to  be 
generally  accepted,  may  be  stated,  and  will  sometimes  aid  in  the  diagnosis. 

Loud  murmurs  without  much  increase  of  cardiac  dulness  point 
towards  congenital  disease,  while  with  increase  of  dulness  they  may  be 
from  either  congenital  or  acquired  disease. 

If  there  are  loud  precordial  murmurs  Avithout  thrill  and  without 
hypertrophy,  which  are  heard  with  greatest  intensity  about  in  the  centre 
of  the  area  of  cardiac  dulness,  the  lesion  is  probably  a  congenital  defect 
of  the  ventricular  septum. 

If  there  is  a  thrill  but  no  hypertrophy,  the  lesion  is  probably  a  con- 
genital patent  ductus  arteriosus. 


■Pia   14-Q 


S,  unclosed  ventricular  septum.    Female,  10  months  old.    'Warren  Museum,  Harvard  University. 

If  there  is  a  loud  murmur  at  the  base,  with  a  weak  pulmonic  second 
sound,  a  thrill,  and  hypertrophy  of  the  right  ventricle,  especially  if  there  is 
marked  and  continued  cyanosis,  the  lesion  is  probably  pulmonary  stenosis. 

Murmurs  of  congenital  origin  must  be  distinguished  from  those  of  a 
functional  or  hsemic  source.  In  congenital  disease  the  murmurs  are  loud, 
often  accompanied  by  a  thrill,  except  in  defect  of  the  ventricular  septum, 
are  associated  with  cyanosis,  dyspnoea,  and  cardiac  hypertrophy,  and  are 
permanent.  Functional  murmurs,  on  the  other  hand,  are  seldom  so  loud, 
are  evanescent,  are  unaccompanied  by  other  marked  signs,  excepting  often 
pronounced  anaemia  and  a  venous  hum,  and  usually  can  be  traced  to 
definite  etiological  conditions  such  as  are  described  on  page  748. 

Fig.  149  shows  a  small  opening  in  the  ventricular  septum. 


728 


PEDIATRICS. 


In  this  case  there  was  also  an  open  foramen  ovale,  but  no  other 
malfonnation.  The  infant,  after  showing  the  usual  progressive  signs  of 
congenital  cardiac  disease,  died  suddenly.  There  was  no  history  of 
cyanosis. 


Piu.    15U. 


Congenital  cardiac  disease.  Male,  4>^  years  old.  Right  and  left  ventricles  laid  open  by  two  cuts. 
Stenosis  of  pulmonary  oritice.  Incomplete  septum  ventriculorum.  1  and  1',  septum  ventrieulorum  cut 
across ;  2,  aortic  valves ;  3,  probe  passing  through  narrowed  pulmonary  orifice  ;  4,  bent  probe,  passing 
through  right  ventricle  to  left  through  opening  in  septum  ventriculorum. 


Fig.  150  represents  a  specimen  taken  from  a  boy  four  and  a  half  years  old,  who 
during  life  had  sho\vn  cyanosis,  clubbed  fingers,  and  at  times  severe  dyspnoea.  The 
physical  signs  in  connection  with  the  heart  were  a  fine  wave  perceptible  to  the  eye  at 
the  left  third  interspace,  a  soft,  purring  thrill  over  the  base  of  the  heart,  cardiac  pul- 
sation 1.4  cm.  (J  inch)  outside  of  the  left  mammillary  line,  and  cardiac  dulness  from 
the  right  sternal  margin  to  the  left  mammillary  line,  with  no  dulness  to  the  right  of  the 
sternum.  A  loud,  harsh  systolic  murmur  was  heard  over  the  left  margin  of  the 
sternum,  most  marked  at  the  second  left  interspace  and  third  rib,  and  not  transmitted 
to  tlie  left  or  along  the  aorta. 

Fig.  151. 


Transverse  section  of  heart  near  afiex.     1,  right  ventricle  :  2,  left  ventricle. 

The  pulmonary  artery  was  abnormally  small,  the  aorta  w^as  abnormally  large,  the 
conus  arteriosus  was  practically  obliterated  at  the  pulmonary  orifice,  and  the  ventricu- 
lar side  formed  a  ring  of  white  cicatricial  tissue  J  cm.  (|  inch)  in  diameter. 

Fig.  151  represents  the  same  heart  with  the  apex  cut  away  so  as  to  show  the  rela- 
tive thickness  of  the  ventricular  walls  and  the  greatly  thickened  septum  A'entriculorum. 

The  right  ventricle  was  markedly  hypertrophied.  The  left  ventricle  was  normal. 
The  ventricular  septum  was  greatly  hypertrophied.     In  this  case  the  ductus  arteriosus 


CONGENITAL   DISEASES   OF   THE    HEART.  729 

was  impervious  and  the  foramen  ovale  practically  closed.  A  foetal  endocarditis  had 
taken  place  before  the  septum  ventriculorum  had  closed.  The  endocarditis  caused 
contraction  of  the  conus,  and  the  blood  being  forced  from  the  right  ventricle  through 
the  imperfect  septum  prevented  the  latter  from  closing.  This  provided  a  safety-valve, 
which,  as  usually  happens  in  this  form  of  malformation,  allowed  the  child  to  live 
longer  than  is  common  in  other  congenital  cardiac  malformations.  The  aorta,  receiving 
a  direct  stream  from  both  ventricles,  was  distended  ;  the  pulmonary  artery,  receiving 
but  little,  remained  small.  It  is  interesting  to  note  in  this  case  that  the  child  passed 
through  an  attack  of  pertussis  and  measles  without  serious  results.  It  died  ultimately 
of  abscess  of  the  brain. 

Fig.  152  shows  an  open  ductus  arteriosus. 


D,  open  ductus  arteriosus.    Male,  16  days  old.    Warren  Museum,  Harvard  University. 


This  heart,  which  was  left  attached  to  the  lung,  was  taken  from  an  infant,  sixteen 
days  old,  who  was  apparently  healthy  at  birth  and  presented  no  symptoms  of  cardiac 
disease. 

When  the  infant  was  five  days  old  it  was  noticed  that  it  would  sometimes  become 
slightly  cyanotic.  At  this  time  its  temperature  rose  to  39.4°  C.  (103°  F.).  A  physical 
examination  showed  nothing  abnormal,  and  nothing  unusual  was  seen  on  inspection. 
The  area  of  cardiac  dulness  was  normal,  and  no  murmurs  were  detected.  A  day  or 
two  later  the  temperature  became  normal ;  the  cyanosis  increased  somewhat,  but  was 
intermittent  and  of  a  very  slight  degree.  At  times  the  skin  would  become  cool.  A 
few  days  later  there  was  slight  intestinal  disturbance.  When  sixteen  days  old,  without 
any  other  symptoms  having  developed,  the  infant  died  suddenly.  The  post-mortem 
examination  showed  this  widely  open  ductus  arteriosus.  The  foramen  ovale  was  also 
open.  There  Were  no  other  lesions,  such  as  stenosis  of  the  pulmonary  artery,  open 
ventricular  septum,  or  lesions  of  the  valves.  The  heart  Avas  of  normal  size.  There 
were  no  signs  of  the  obliterative  endocarditis  usually  found  at  this  age  in  the  ductus 
arteriosus. 


730  PEDIATRICS. 

General  Treatment. — The  treatment  of  congenital  disease  of  the 
heart  is  essentially  hygienic  and  symptomatic.  The  infants  should  be 
carefully  protected  from  atmospheric  changes  which  would  be  likely  to 
produce  bronchial  irritation,  as  in  many  cases  bronchitis  appears  to  play 
an  important  part  in  interfering  with  the  mamtenance  of  the  equilibrium 
of  the  circulation  and  in  destroying  compensation.  In  a  number  of  cases 
I  haA'e  found  that  the  administration  of  digitalis  in  small  doses  and  ^^'ith 
the  greatest  caution  is  valuable  when  hypertrophy  has  begun  to  fail  and 
dilatation  to  increase.  When  the  dyspnoea  is  distressing,  a  few  drops  of 
aromatic  spirits  of  ammonia  will  often  give  relief.  Stimulants  are  usually 
indicated. 

Freedom  from  excitement  and  over-exertion  should  be  constantly  en- 
forced, but  the  child  should  be  kept  in  the  open  air,  when  it  is  warm  and 
dry,  as  much  as  possilDle.  Finally,  infants  and  children  with  congenital 
cardiac  disease  should  be  closely  watched,  even  when  they  seemingly  are 
doing  well,  for  they  are  apt  to  die  suddenly. 

ACQUIRED  DISEASES  OF  THE  HEART. 

In  studying  acquired  diseases  of  the  heart  it  is  important  to  recog- 
nize the  relative  size  and  position  of  the  heart  at  different  ages.  These 
have  been  described  on  page  85.  Acquired  chseases  of  the  heart  are 
more  apt  to  attack  the  left  side  of  the  heart  than  the  right ;  when  the 
right  heart  is  affected  it  is  generally  secondary  to  the  lesions  on  the  left 
side. 

There  are  certain  differences  between  the  symptoms  of  cardiac  disease 
in  infancy  and  early  life  and  those  in  later  life.  In  young  children  mur- 
murs are  more  apt  to  be  diffuse  than  in  adults,  often  being  heard  over  the 
entire  chest ;  and  the  rate  and  rhythm  of  the  heart  are  so  easily  disturbed 
by  nervous  mfluences  as  to  be  of  little  diagnostic  value.  Progressive 
emaciation  is  a  symptom  which  is  apt  to  be  pronounced  and  to  appear 
^ — ^arly  in  the  disease,  especially  if  the  child  is  young. 

An  enlarged  heart  dependent  on  adhesions  from  a  preceding  pericar- 
ditis is  more  common  in  early  life  than  m'  adults,  while  compensation  is 
much  more  readily  accpired.  We  have  had  children  with  cardiac  disease 
at  our  children's  clinic  one  year  with  cardiac  symptoms  so  severe  that  they 
had  to  be  carried ;  they  were  emaciated  and  cyanotic,  the  area  of  cardiac 
dulness  was  increased,  and  souffles  were  present ;  yet  these  same  children 
would  return  and  be  shov^Ti  to  the  next  class  of  students  in  the  following 
year,  walkmg  up-stau-s  \^'ithout  dyspnoea,  looking  well  nourished,  of  good 
color,  T\ith  much  less  enlargement  of  the  area  of  cardiac  dulness,  and 
with  the  cardiac  souffles  scarcely  perceptible,  showing  that  the  cardiac 
compensation  was  complete. 

Cardiac  symptoms  dependent  on  organic  lesions  may  arise  and  yet  no 
physical  signs  of  such  lesions  be  detected  during  life. 


ACQUIRED    DISEASES    OF   THE    HEART.  731 

CARDIAC  HYPERTROPHY. 

Hypertrophy  of  the  heart  consists  of  an  mcrease  in  thickness  of  the 
cardiac  walls.  It  may  be  of  one  or  both  sides  of  the  heart  and  is  usually 
most  marked  in  the  ventricles.  The  hypertrophy  may  be  of  the  walls 
without  an  accompanying  dilatation  of  the  cardiac  cavities  (eccentric),  or 
dilatation  of  the  ca^^lties  may  be  present,  thus  increasing  the  entire  size  of 
the  heart.  Cai'diac  hjpertrophy  is  always  an  effort  of  nature  to  counter- 
act various  morbid  influences  by  maintaining  the  equilibrium  of  the  circu- 
lation,— that  is,  it  is  compensatory. 

Etiology. — Hypertrophy  of  the  heart  is  not  in  itself  a  disease,  but  may 
occur  in  many  diseases  whether  of  the  walls  or  of  the  valves.  It  is 
closely  related  to  increased  blood-pressure,  which  may  arise  from  disease 
or  circulatory  disturbance  outside  of  the  heart  or  from  imperfect  valvular 
conditions  within  the  heart. 

In  the  former  case  the  most  common  causes  in  children  are  pericardial 
adhesions,  prolonged  pertussis,  narro\^-ing  of  the  aorta,  and  nephritis,  espe- 
cially that  which  follows  scarlet  fever.  iMechanical  interference  with  the 
action  of  the  heart  arising  from  adhesions  of  the  pericardium  is  often 
latent  in  its  symptoms  in  infancy,  and  its  occurrence  should  be  especially 
borne  in  mind.  In  the  valvular  lesions  the  increased  demand  for  cardiac 
work  beyond  what  is  normally  called  for  acts  as  an  immediate  cause  for 
cardiac  hypertrophy. 

Pathological  Anatojiy. — The  chief  morbid  conditions  of  cardiac  hyper- 
trophy are  an  increase  in  weight  and  an  increase  in  size  and  number  of 
the  muscular  fibres  which  is  found  not  only  in  the  cardiac  walls  but  in 
the  papillse  and  trabeculse.  If  tlie  left  side  of  the  heart  is  conspicuously 
enlarged,  as  in  obstruction  at  the  aortic  orifice  or  in  the  general  arterial 
system,  the  heart  is  elongated  ;  if  the  hypertrophy  is  of  the  right  side,  as 
in  obstruction  of  the  pulmonary  circulation,  the  heart  is  widened. 

Symptoms. — So  long  as  the  compensation  is  complete,  cardiac  hyper- 
trophy does  not  produce  in  young  subjects  any  marked  symptoms,  even 
the  dyspnoea  on  exertion  not  being  especially  noticeable. 

Hypertrophy  of  the  Left  Ventricle. — In  hypertrophy  of  the  left  ventricle 
the  cardiac  impulse  is  perceptible  over  an  abnormally  large  area  and  the 
impulse  is  lower  and  further  to  the  left  than  normal,  the  degree  varying 
according  to  the  extent  of  the  hypertrophy. 

Palpation  shows  the  impulse  to  be  increased  in  force.  Percussion 
shows  the  cardiac  dulness  to  be  markedly  increased  in  extent  downward 
and  to  the  left.  x4.uscultation  shows  the  first  somid  at  the  apex  to  be  long 
and  low  in  comparison  with  the  second  sound,  which  is  loud  and  sharp. 
There  is  accentuation  of  the  aortic  second  sound.  The  pulse  is  full  and 
strong. 

Hypertrophy  of  the  Right  Ventricle. — In  hypertrophy  of  the  right  ven- 
tricle the  cardiac  impulse  is  especially  marked  further  to  the  left  than 


732  PEDIATRICS. 

normal  and  somewhat  downward.  There  is  nothing  characteristic  in  the 
pulse.  The  area  of  superficial  cardiac  dulness  is  increased  in  width, 
notably  to  the  right  and  often  beyond  the  right  sternal  line.  There  is 
accentuation  of  the  pulmonic  second  sound,  but  this  accentuation,  al- 
though almost  always  present  in  hypertrophy  of  the  right  ventricle,  is  not 
peculiar  to  this  condition,  as  it  may  be  present  in  varying  degrees  in 
young  children  normally  and  from  such  causes  as  pneumonia  and  certain 
nervous  conditions. 

Prognosis. — So  long  as  full  compensation  is  present  the  prognosis  is 
favorable.  It  becomes  proportionately  unfavorable  as  the  compensation 
lessens. 

Treatment. — The  treatment  is  described  on  page  746. 

CARDIAC    DILATATION. 

Cardiac  dilatation  occurs  when  the  cavities  of  the  heart  are  abnor- 
mally increased  m  volume.  In  many  cases  there  is  a  thinning  of  the 
walls  of  the  heart,  as  in  acute  dilatation,  but  when  hypertrophy  is  present, 
as  in  certam  chronic  cases,  the  walls  may  be  thicker  than  normal. 

Etiology. — Acute  dilatation  may  occur  from  a  weakening  of  the  cardiac 
muscle  caused  by  degeneration  of  the  myocardium,  as  in  certain  infec- 
tious diseases  and  from  poor  nutrition. 

Chronic  dilatation  occurs  slowly  as  the  result  of  valvular  lesions  or  in 
the  progress  of  the  circulatory  disturbances  spoken  of  as  causing  hyper- 
trophy. 

Pathological  Anatomy. — In  simple  dilatation,  without  hypertrophy, 
the  weight  of  the  heart  is  not  increased,  although  there  is  increase  in  its 
size.  The  papillte  are  flattened,  when  the  dilatation  is  marked,  in  com- 
parison with  the  accompanying  hypertrophy,  and  the  endocardium  is 
thickened  and  opacjue. 

Symptoms. — The  symptoms  ot  cardiac  dilatation  are  essentially  those 
of  a  failure  of  compensation  characterized  by  dyspnoea  on  exertion,  pal- 
^ — pitation,  cough,  and,  later,  cyanosis  and  oedema.  In  both  acute  and 
chronic  dilatation  there  are  a  weak,  fluttering  apex-beat  and  pulse,  an 
increased  area  of  cardiac  dulness,  and  valvular  murmurs  varying  accord- 
ing to  the  especial  lesions. 

Dilatation  of  the  Left  Ventricle. — There  is  an  increased  area  of  cardiac 
dulness  to  the  left  and  downiward.  The  first  heari-sounds  are  sharp  and 
short.  The  aoriic  second  sound  is  feeble  both  at  the  apex  and  in  the 
aortic  area. 

Dilatation  of  the  Right  Ventricle. — The  chief  signs  of  dilatation  of  the 
right  ventricle  are  increase  of  the  area  of  cardiac  dulness  to  the  right, 
corresponding  to  the  region  of  the  right  auricle,  and  a  weak  pulmonic 
second  sound. 

In  all  the  conditions  which  cause  dilatation  there  is  a  greater  lial^ility 
that  acute  dilatation  may  take  place  in  early  life  than  at  a  later  period. 


ACQUIRED   DISEASES   OF   THE    HEART.  733 

The  processes  which  suddenly  cause  great  increase  of  the  blood-pressure 
in  the  lungs  may  lead  to  acute  dilatation  of  the  right  ventricle.  When 
there  is  a  diffuse  renal  disease,  such  as  may  develop  in  the  course  of 
scarlet  fever,  acute  dilatation  of  the  left  ventricle  may  take  place,  and  be 
followed  by  hypertrophy.  In  all  these  diseases  this  acute  dilatation  may 
take  place  rapidly  and  disappear  almost  as  rapidly,  a  phenomenon  which 
is  somewhat  characteristic  of  cardiac  disease  in  early  life. 

The  great  changes  which  take  place  in  the  heart  and  its  rapid  growth 
at  the  time  of  puberty  have  already  been  referred  to.  At  this  period  the 
general  growth  of  the  child  is  apt  to  be  verv^  rapid,  and  symptoms  of  car- 
diac weakness  commonly  occur,  especially  in  girls.  These  symptoms  are 
debility,  lack  of  energy,  palpitation,  and  dyspnoea  on  exertion.  There 
may  also  be  signs  of  slight  cardiac  dilatation,  and  murmurs,  probably 
hsemic  in  their  nature.  This  period,  therefore,  is'  one  in  which  cardiac 
disease  from  any  cause,  such  as  rheumatic  fever,  is  more  serious  than  at  a 
later  period,  when  the  heart  is  not  taxed  by  too  rapid  growth. 

Prognosis. — The  prognosis  of  cardiac  dilatation  depends  on  whether 
the  cause  is  a  temporary  one  or  whether,  in  case  it  is  not,  compensatory 
hypertrophy  can  be  obtained  by  treatment.  Whether  the  prognosis  is 
favorable  or  unfavorable  must,  then,  be  determined  by  the  evidence  of  re- 
action which  is  presented  by  the  individual  case. 

Treatmext. — The  treatment  is  described  on  page  746. 

MYOCARDITIS. 

Primarj"  disease  of  the  myocardium  is  ven^  rare  in  children,  in  whom 
disease  of  the  myocardium  is  almost  always  a  secondary  process  resultmg 
from  one  of  the  infectious  diseases.     It  may  be  acute  or  chronic. 

Etiology. — The  most  common  causes  in  children  are  endocarditis, 
pericarditis,  and  the  infectious  diseases,  especially  scarlet  fever  and  diph- 
theria. The  other  causes  which  may  produce  an  affection  of  the  myo- 
cardium in  later  life  may  occur  at  any  age,  but  are  too  rare  in  children  to 
be  considered.  They  are  found  in  lesions  of  the  coronar}"  arteries 
(aneemic  necrosis),  an  excess  of  food,  alcohol,  physical  strain,  and  arterio- 
sclerosis. 

Pathological  Anatomy. — The  lesions  may  be  parenchymatous  or  inter- 
stitial, degenerative  or  inflammatory.  They  are  essentially  of  the  septum 
and  left  ventricle.  In  the  parenchymatous  form  the  anatomical  changes  are 
in  the  muscle-cells,  the  cells  being  degenerated  in  various  ways  (granular, 
fatty,  hyaline),  and  the  muscular  fibres  often  separated,  a  condition  known 
as  fragmentation  and  segmentation.  This  form  is  usually  met  with  in 
fevers,  intoxications,  infectious  conditions,  and  in  connection  with  endo- 
carditis and  pericarditis.  It  is  always  acute,  usually  diffuse,  and  is 
especially  characterized  by  softness  of  the  heart. 

The  inter stitiat form  may  be  acute  or  chronic,  and  occurs  in  small  areas. 
In  the  acute  variety,  such  as  occurs  in  certain  infectious  diseases,  most 


734  PEDIATRICS. 

commonly  in  diphtheria  and  typhoid  fever,  and  especially  in  acute  pericar- 
ditis, which  is  an  important  local  cause  in  childhood,  there  is  an  infiltra- 
tion of  round,  cells  between  the  fibres,  and  in  some  cases  small  abscesses 
are  formed.  In  the  chronic  variety  there  are  opaque,  white  or  yellow 
spots  wdiich  later  may  soften  (Ziegler's  myomalacia),  and,  as  has  occurred 
in  rare  cases  in  children,  cardiac  aneurism  and  rupture  may  result.  The 
parenchymatous  and  interstitial  lesions  of  the  myocardium  may  develop 
alone  or  in  combination.  The  other  pathological  lesions  of  the  myocar- 
dium are  so  rare  in  children  that  they  need  merely  be  mentioned.  They 
are  fatty  degeneration  and  infiltration^  brovm  atrophy,  amyloid  degeneration, 
hyaline  transformation  (Zenker),  and  calcareous  degeneration. 

Symptoms. — The  symptoms  are  essentially  those  of  a  weak  heart,  but 
as  to  whether  such  symptoms  are  indicative  of  an  affection  of  the  myo- 
cardium, or  of  nervous  conditions  of  the  heart,  or  of  some  other  cardiac 
disease  is  usually  very  uncertain. 

In  acute  cases  there  may  be  palpitation,  pallor,  dyspnoea  on  slight 
exertion,  a  rapid,  irregular,  weak  pulse,  disturbance  of  digestion,  and  on 
auscultation  feeble  heart-sounds,  especially  the  aortic  second,  and  in  the 
beginning  absence  of  murmurs.  Usually  there  is  no  increase  in  cardiac 
dulness. 

It  must,  how'ever,  be  remembered  that  these  same  symptoms  may  be 
present  and  yet  no  lesion  of  the  myocardium  be  found  at  the  autopsy, 
Avhile,  on  the  other  hand,  w-ithout  any  especial  symptoms  referable  to  the 
heart,  sudden  death  may  occur  and  marked  lesions  of  the  myocardium  be 
present. 

In  chronic  cases  the  weakening  of  the  heart  is  slow  and  progressive 
and  the  area  of  cardiac  dulness  is  increased,  corresponding  usually  to  the 
left  side  of  the  heart.  The  impulse  is  feeble  and  murmurs  may  eventually 
appear  as  the  valves  of  the  heart  become  incompetent.  Symptoms  of 
venous  stasis  gradually  supervene.  The  pulse  is  irregular  and  small ; 
it  is  sometimes  slow,  but  becomes  rapid,  under  even  slight  nervous  ex- 
~citement.  All  these  symptoms  may  become  intensified,  but  it  must  be 
borne  in  mmd  that  other  diseases  may  cause  these  same  cardiac  symptoms 
and  that  the  autopsy  may  disclose  serious  chronic  lesions  of  the  cardiac 
walls  where  during  life  no  cardiac  symptoms  had  appeared. 

Diagnosis. — The  diagnosis  depends  upon  symptoms  of  cardiac  weak- 
ness, with  a  rapid,  irregular,  feeble  pulse,  without  murmurs,  with  or  with- 
out increased  cardiac  dulness,  upon  the  progressive  character  of  the  symp- 
toms, and  upon  the  comparatively  slight  improvement  under  treatment. 
The  etiological  factor  in  the  diagnosis  is  important.  When  a  previously 
healthy  chiid  has  been  attacked  by  one  of  the  infectious  diseases,  such  as 
scarlet  fever,  diphtheria,  or  typhoid,  and  when  cardiac  symptoms  not  re- 
ferable to  an  endocarditis  or  pericarditis  arise,  we  may  suspect  a  lesion 
of  the  myocardium. 

Prognosis. — The  prognosis  in  affections  of  the  myocardium  depends 


ACQUIRED   DISEASES   OF   THE    HEART.  735 

upon  the  cause  of  the  condition  and  also,  if  it  is  secondary  to  one  of  the 
infectious  diseases,  upon  the  degree  and  virulence  of  the  infection.  It  is, 
therefore,  very  uncertain  in  the  acute  cases,  although  always  serious, 
while  in  the  chronic  cases  it  is  very  grave. 

Treatment. — The  treatment  is  essentially  rest  and  freedom  from  ner- 
vous excitement  and  sudden  exertion,  as  from  sitting  up  in  bed.  After 
such  diseases  as  diphtheria  a  recumbent  position  is  often  indicated  for 
weeks  when  marked  signs  of  cardiac  w^eakness  have  arisen ;  and  this 
may  be  said  also  when  these  symptoms  supervene  on  any  of  the  infectious 
diseases.  Stimulants  such  as  aromatic  spirits  of  ammonia  and  alcohol 
should  be  freely  used.  Strychnine  is,  of  all  drugs,  perhaps  the  most  valu- 
able, while  digitalis,  if  used  at  all,  should  be  given  with  great  caution  and 
in  small  doses.  When  there  is  much  precordial  distress  and  the  symp- 
toms of  cardiac  failure  are  imminent,  small  doses  of  morphia  given  subcu- 
taneously  are  indicated.  Anaemia  and  other  symptoms,  if  present,  should 
receive  appropriate  symptomatic  treatment. 

ENDOCARDITIS. 

Endocarditis  is  an  inflammation  of  the  endocardium  which  is  usually 
confined  to  the  valves.     It  may  be  acute  or  chronic. 

Acute  Endocarditis. — The  acute  form  of  endocarditis  may  occur  in 
foetal  life,  and  in  these  cases  almost  invariably  affects  the  right  side  of  the 
heart,  while  if  the  disease  is  acquired  in  extra-uterine  life  it  is  the  left  side 
of  the  heart  which  is  most  frequently  attacked. 

Etiology. — Acute  endocarditis  may,  in  rare  instances,  be  a  primary 
disease,  but  in  most  cases  is  caused  by  some  one  of  various  infectious 
processes.  In  some  cases  bacteria  have  been  found,  but  not  in  all.  There 
is  no  one  variety  of  bacteria  exclusively  concerned  in  the  production  of 
acute  endocarditis.  The  streptococcus,  staphylococcus,  pneumococcus,  and 
gonococcus  are  the  forms  which  have  been  most  frequently  found.  Less 
frequently,  especially  in  the  simple  form  of  acute  endocarditis,  the  tubercle 
bacillus,  the  typhoid  bacillus,  and  the  anthrax  bacillus  have  been  met  with. 
The  colon  bacillus,  diphtheria  bacillus,  bacillus  pyocyaneus,  and  bacillus 
of  influenza  have  also  been  reported.  There  is  no  difference  in  the  endo- 
carditis arising  from  these  various  organisms  except  in  the  degree  of  the 
malignant  nature  of  the  especial  organism  which  has  produced  the  disease, 
or  in  the  vulnerability  to  infection  of  the  individual. 

The  frequent  occurrence  of  acute  endocarditis  in  children  has  been 
attributed  to  the  greater  vulnerability  to  bacterial  action  in  early  life. 

Acute  endocarditis  may  be  of  the  simple  or  verrucose  or  of  the  septic 
or  malignant  form ;  this  distinction,  however,  is  based  on  the  intensity  of 
the  endocarditis  rather  than  on  marked  etiological  differences.  The 
malignant  form  is  very  rare  in  childhood. 

The  most  frequent  etiological  factor  in  simple  acute  endocarditis  is 
rheumatic  fever.     It  may  also  occur  in  chorea  either  with  or  without 


736  PEDIATRICS. 

a  rheumatic  complication.  While  it  may  occur  in  the  course  of  any  of 
the  infectious  diseases,  such  as  influenza  and  diphtheria,  it  is  most  com- 
mon in  scarlet  fever,  pneumonia,  and  pleurisy,  while  it  is  not  common  in 
measles  and  varicella.  The  malignant  form  of  endocarditis  seems  to  occur 
more  frequently  in  pneumonia  than  in  any  of  the  other  acute  infectious 
diseases. 

When  the  lesions  of  endocarditis  are  found  in  children,  the  connective 
tissue  and  the  basement  substance  are  principally  concerned  in  the  in- 
flammatory process.  The  endocardium  which  forms  the  valves  is  that 
which  is  most  frequently  inflamed,  but  other  portions  of  it  are  by  no 
means  exempt.  In  some  cases  there  is  swelling  of  the  valves,  which  are 
thickened,  their  surfaces  remaining  smooth,  the  basement  substance  is 
swollen,  and  there  is  a  moderate  production  of  new  connective-tissue  cells. 
In  other  cases  the  growth  of  connective-tissue  cells  is  very  much  more 
marked,  the  basement  substance  is  broken  up,  and  little  cellular  fungus- 
masses,  called  vegetations,  project  from  the  free  surface  of  the  endocar- 
dium (verrucous  endocarditis). 

On  the  surface  of  these  vegetations  thrombi  may  be  formed,  and 
bacteria  are  sometimes  present.  In  still  other  cases  the  cellular  growth 
in  some  places  forms  vegetations,  and  in  others  degenerates,  and  thus 
portions  of  the  valves  are  destroyed.  This  is  acute  ulcerative  endocarditis^ 
also  called  malignant  endocarditis.  In  these  cases  the  diseased  valve  and 
the  thrombi  contain  bacteria  much  more  frequently  and  in  far  greater 
numbers  "than  are  found  in  the  simple  benign  form.  This  malignant  form 
is  evidently  secondary  in  the  course  of  a  septic  infection,  and  the  previous 
disease  of  the  valves  favors  the  invasion  of  the  infectious  bacteria.  In 
the  simple  form  of  acute  endocarditis  emboli  may  occur,  which  from  their 
size  usually  produce  mechanical  disturbances  alone,  while  in  the  malig- 
nant form  the  emboli  are  usually  smaller,  and,  being  septic,  produce  in- 
flammatory rather  than  mechanical  disturbance,  giving  rise  to  miliary 
abscesses  in  various  parts  of  the  body,  such  as  the  liver,  kidneys,  spleen, 
^ — stomach,  intestine,  brain,  eye,  joints,  and  skin.  Acute  endocarditis  may 
also  be  secondary  to  old  cardiac  malformations  or  lesions  (endocarditis 
recurrens). 

In  some  cases  the  children  recover,  and  the  A^alves  seem  to  return  to 
their  normal  condition,  while  in  others  the  valves  are  left  permanently 
damaged. 

Simple  Acute  Endocarditis. — Symptoms. — The  symptoms  of  simple 
acute  endocarditis  are  often  obscure,  and  in  infants  and  young  children  in 
the  beginning  are  apt  to  be  latent.  When  the  disease  arises  in  connection 
with  some  other  disease,  the  symptoms  are  especially  likely  to  be  masked 
by  those  of  the  disease  which  it  complicates.  In  some  cases  the  endocar- 
ditis develops  insidiously  without  any  additional  symptoms,  such  as  pain 
or  precordial  distress,  and  its  presence  is  not  recognized  until  a  careful  ex- 
amination of  the  heart  detects  a  murmur  ;  in  others,  pronounced  and  even 


ACQUIRED   DISEASES   OF   THE   HEART.  737 

violent  cardiac  symptoms  are  present  from  the  beginning.  Again,  the  first 
evidence  of  an  endocarditis  may  come  from  symptoms  of  emboHsm  such 
as  hemiplegia,  heematuria,  dyspnoea,  cough  or  localized  pain,  as  in  the 
thorax  or  abdomen.  If  the  muscular  tissue  is  involved  as  well  as  the 
endocardium,  the  general  cardiac  symptoms  of  dyspnoea,  cyanosis,  and 
palpitation  are  still  more  marked. 

When  endocarditis  arises  in  the  course  of  acute  rheumatic  fever  there 
may  be  nothing  which  would  draw  especial  attention  to  the  heart,  but 
there  are  usually  general  symptoms  of  increased  rapidity  of  the  heart's 
action,  with  perhaps  slight  irregularity,  restlessness,  prostration,  and  a 
rise  in  the  temperature,  wMch  is  especially  suspicious  if,  with  this  in- 
crease in  the  fever,  there  is  no  exacerbation  of  the  trouble  in  the  joints. 
Palpitation  and  dyspnoea  are  also  cjuite  frequently  present.  There  may  at 
first  be  no  murmur,  but  usually  after  a  few  days  a  soft  systolic  murmur 
at  the  apex  transmitted  to  the  left,  and  later  a  slightly  accentuated  pul- 
monic second  sound,  may  be  heard.  Endocarditis  may  with  these  same 
symptoms  occur  in  the  course  of  chorea. 

^Vhen  endocarditis  does  not  arise  as  a  complication  of  some  other 
disease,  the  symptoms  at  the  onset,  when  prominent,  are  usually  a  rise 
of  temperature,  an  accelerated  and  sometimes  weak  and  irregular  pulse, 
dyspnoea,  palpitation,  and  more  or  less  precordial  distress.  All  these 
symptoms  vary  according  to  the  extent  of  the  lesions.  Later  they  depend 
upon  whether  or  not  compensation  has  been  established.  In  connection 
with  these  early  symptoms,  cardiac  dilatation  and  cyanosis  are  very  apt  to 
occur.  When  the  disease  has  advanced  so  far  as  to  interfere  with  com- 
pensation, the  physical  signs  of  dilatation  appear.  The  symptoms  differ 
somewhat  according  as  the  inflammatory  condition  has  begun  in  the 
valves  or  in  the  cardiac  walls  (Stefi'en).  In  the  former  case  the  signs 
of  dilatation  accompany  those  of  valvular  weakness,  while  in  the  latter 
the  symptoms  of  dilatation  come  first,  and  are  followed  by  the  mechanical 
results  of  valvular  insufficiency. 

In  a  first  attack  of  acute  endocarditis  the  serious  symptoms  connected 
with  great  lack  of  compensation  which  are  met  with  when  the  attack 
supervenes  on  a  previous  cardiac  lesion  are  not  likely  to  arise.  In  some 
cases,  however,  when  the  individual  power  of  cardiac  resistance  is  slight, 
they  appear  early  in  the  disease.  Under  these  circumstances  the  child 
emaciates  rapidly,  becomes  very  weak  and  anaemic,  and  the  cyanosis  and 
dyspnoea  increase.  There  is  apt  to  be  cough  from  an  accompanying 
bronchial  irritation,  produced  most  frequently  when  there  is  obstruction 
at  the  mitral  orifice.  As  a  result  of  a  general  venous  stasis,  enlargement 
of  the  liver,  haemoptysis,  and  oedema  of  the  face,  legs,  and  arms  appear. 
Children  show  such  recuperative  power  that  even  in  these  advanced  cases 
under  proper  treatment  the  serious  symptoms  often  gradually  pass  away 
and  such  complete  cardiac  compensation  takes  place  that  they  are  left  with 
no  symptoms  of  cardiac  disease  except  a  murmur  and  some  hypertrophy. 

47 


738  PEDIATRICS. 

Relapses  are  common  and  there  is  a  great  tendency  to  recurrence. 
Embolism  may  take  place  as  a  late  as  well  as  an  early  complication. 
Anaemia  is  a  very  common  symptom,  especially  when  endocarditis  ac- 
companies rheumatic  fever.  Congestion  of  the  lungs  with  resulting 
haemoptysis  may  arise  when  there  is  insufficiency  of  the  mitral  valve. 
When  the  valves  are  affected  murmurs  are  usually  present,  yet  sometimes 
when  there  are  lesions  of  the  valves  murmurs  cannot  be  detected.  In  endo- 
carditis murmurs  are  most  frequently  heard  in  the  region  of  the  mitral 
valve,  and  insufficiency  of  the  mitral  valve  is  the  most  common  of  the 
imflammatory  cardiac  lesions  of  childhood. 

Acute  simple  endocarditis  may  last  for  several  weeks,  the  symp- 
toms gradually  subsiding  or  becoming  chronic  ;  or  there  may  be  recur- 
rent attacks  which  are  especially  likely  to  result  in  chronic  valvular  dis- 
ease ;  or  acute  dilatation  may  result  with  increasing  symptoms  of  cardiac 
insufficiency,  dropsy,  and  pulmonary  complications,  finally  ending  in 
death. 

Diagnosis. — The  diagnosis  of  simple  acute  endocarditis  during  life  de- 
pends upon  the  physical  signs.  These  signs  are  an  increase  in  the  area 
of  cardiac  dulness  and  a  change  in  the  sounds  of  the  heart.  The  change 
in  the  area  of  cardiac  dulness  must  be  differentiated  from  that  which 
occurs  in  a  pericardial  effusion  as  described  on  page  759. 

The  change  in  the  cardiac  sounds  may  be  produced  by  changes  in  the 
blood  or  by  organic  lesions  of  the  valves.  The  differential  diagnosis  be- 
tween these  two  conditions  is  given  on  page  748,  and  the  diagnosis  of  the 
especial  valvular  lesion  is  given  on  pages  741-745. 

Prognosis. — The  prognosis  of  simple  acute  endocarditis  in  early  life  is 
comparatively  favorable  as  to  the  immediate  outcome,  but  may  eventually 
become  serious  by  the  occurrence  of  embolism  or  the  development  of  a 
malignant  endocarditis.  The  usual  course  of  the  mild  cases  lasts  from 
two  to  three  weeks,  the  fever  first  subsiding  and  the  cardiac  symptoms 
gradually  disappearing.  There  is  ahvays  danger  of  recurrent  attacks. 
/^  The  damage  done  to  the  valves  of  the  heart  can  only  be  told  by  the 
subsequent  history  of  the  symptoms.  Owing  to  the  great  recuperative 
powers  in  early  life,  in  many  cases,  especially  when  it  is  the  first  attack, 
such  complete  compensation  takes  place  that  the  child  practically  re- 
covers. If  it  is  the  walls  of  the  heart  that  are  affected,  the  heart  may 
regain  its  normal  size  and  position.  If  the  valves  alone,  or  the  valves 
and  the  walls,  are  affected,  recovery  can  still  take  place.  The  devel- 
opment of  chronic  valvular  disease  is  the  usual  termination.  Death 
may,  however,  occur  at  the  heighth  of  the  attack,  or  the  child  may 
die  later  from  exhaustion,  and  sometimes  dies  suddenly  from  heart- 
failure. 

Malignant  Endocarditis. — Symptoms. — The  symptoms  of  malignant 
endocarditis  are  necessarily  varied  and  indefinite,  arising  as  they  usually 
do  in  the  course  of  some  other  disease  with  simply  an  exacerbation  of 


ACQUIRED    DISEASES   OF   THE    HEART.  739 

the  previous  symptoms,  especially  of  the  temperature.  There  are  usually 
the  general  symptoms  of  intermittent  temperature,  sweating,  delirium, 
and  failure  in  strength.  Two  types  of  the  disease,  septic  or  pyasmic  and 
typhoidal,  are  recognized.  The  septiG  type  is  characterized  by  the  signs 
of  septic  infection,  rigors,  sweating,  and  irregular  temperature,  while  the 
typhoidal  type  shows  diarrhoea,  dry  tongue,  distended  and  tympanitic  abdo- 
men, enlargement  of  the  spleen,  profuse  sweating,  and  a  petechial  efflores- 
cence on  the  skin.  A  clear  distinction  between  the  two  forms,  however, 
is  often  not  marked.  Cerebral  symptoms  may  arise,  and  simulate  menin- 
gitis and  malaria.  Embolic  processes  may  produce  special  symptoms, 
such  as  paralysis,  coma,  bloody  urine,  retinal  hemorrhage,  peritonitis  from 
infarction  of  the  spleen,  and  in  some  cases  pulmonary  symptoms  simu- 
lating pneumonia.  Murmurs  may  be  absent.  The  duration  of  the  at- 
tack depends  mostly  on  the  disease  to  which  it  is  secondary,  and  may 
vary  from  a  few  days  to  as  many  weeks.  A  marked  leucocytosis  is 
present. 

Diagnosis. — The  diagnosis  of  malignant  endocarditis  is  made  from  the 
simple  form  by  the  graver  constitutional  signs,  the  higher  temperature,  and 
the  septic  or  typhoidal  symptoms  just  described.  From  typhoid  fever  it 
is  to  be  distinguished  by  its  abrupt  onset,  irregular  temperature,  pre- 
cordial pain  and  distress,  marked  leucocytosis,  and  negative  Widal  reac- 
tion. Malaria  can  be  eliminated  by  the  absence  of  the  plasmodium  ma- 
larise  and  the  presence  of  leucocytosis. 

Prognosis. — The  prognosis  of  malignant  endocarditis  is  very  grave, 
although  the  disease  is  not  necessarily  fatal.  The  heart  is,  however, 
permanently  damaged. 

Treatment  of  Acute  Endocarditis. — The  treatment  of  acute  endo- 
carditis during  the  early  days  of  the  attack  is  essentially  rest  in  bed. 
When  the  disease  is  due  to  some  specific  disease,  such  as  diphtheria,  the 
specific  remedy  for  that  disease  should  be  given  at  once.  From  the  very 
beginning,  however,  we  should  endeavor  to  establish  compensation.  The 
child  should  be  encouraged  to  sleep,  in  order  that  the  circulation  may  be 
kept  as  quiet  as  possible  and  thus  relieve  the  work  of  the  disabled  heart. 
The  heart-beats  of  a  young  child  during  sleep  are  often  reduced  twenty  in 
a  minute,  and  thus  sleep  affords  the  best  opportunity  for  compensation. 
Later  the  general  health  of  the  child  should  be  carefully  attended  to  by 
means  of  good  food,  pure  air,  and  exercise  of  a  mild  type,  never  exces- 
sive. The  surface  circulation  should  be  promoted  by  baths  and  gentle 
massage.  Digitalis  and  iron  are  of  great  value,  the  former  in  aiding  the 
establishment  of  compensation,  the  latter  in  combating  the  anaemia. 
When  there  are  symptoms  of  heart-failure,  stimulants  such  as  alcohol, 
aromatic  ammonia,  and  strychnine  (page  464)  are  indicated  and  important. 
If  at  any  time  during  the  course  of  the  disease  the  attacks  of  dyspnoea 
are  excessive,  nitroglycerin  can  be  given  in  doses  proportionate  to  the  age 
of  the  child ;  0.0003  gramme  (2-^0  grain)  can  be  given  to  a  child  three  or 


740  PEDIATRICS. 

four  years  old.     The  younger  the  child,  the  more  likely  it  is  that  we  shall 
have  to  contend  with  a  resulting  atrophic  condition  and  antemia. 

The  treatment  of  the  malignant  form  of  endocarditis  is  essentially  that 
of  a  septic  condition,  and  stimulants  should  be  used  freely. 

CHRONIC   ENDOCARDITIS. 

Chronic  endocarditis  showing  sclerosis  of  the  valve  may  be  chronic 
from  the  outset,  but  it  usually  succeeds  an  acute  endocarditis  ;  this  occurs 
especially  in  the  rheumatic  form. 

Etiology. — The  usual  causes  of  chronic  endocarditis  in  later  life,  such 
as  syphilis,  alcohol,  gout,  and  strain  from  undue  muscular  exertion,  are  very 
seldom  met  with  in  children,  acute  endocarditis  being  the  chief  etiological 
condition. 

Pathological  Anatomy. — Although  the  morbid  process  may  attack  the 
parietal  endocardium,  it  is  the  valvular  form  that  is  of  such  clinical  impor- 
tance as  to  become  the  prominent  feature  in  chronic  endocarditis.  The  proc- 
ess in  extra-uterine  life  most  frequently  affects  the  aortic  and  mitral  valves, 
the  latter  being  especially  involved  in  childhood.  It  is  a  slow,  insidious 
process,  manifested  by  thickening,  induration,  and  adhesions,  followed  by 
a  contraction  of  the  valvular  segments.  Later,  lime-salts  are  deposited  in 
the  A^alves  and  this  results  in  rigidity.  As  the  sclerotic  changes  increase, 
the  deformity  of  the  segments  becomes  greater  and  results  either  in  im- 
perfect closure  of  the  valves  {valvular  insufficiency),  allowing  a  regurgitation 
of  the  blood,  or  the  orifice  is  narrowed  (valvular  stenosis),  causing  obstruc- 
tion to  the  blood-current.  We  meet,  especially  in  children,  with  lesions 
at  the  mitral  orifice  in  which  the  valves  are  curled  and  thickened  so 
that  they  are  insufficient,  although  there  may  be  no  narrowing  of  the 
orifice.  The  chordse  tendinese  gradually  become  shortened.  The  apices 
of  the  papillary  muscles  are  enlarged,  the  endocardium  becomes  thickened, 
and  marked  changes  following  the  valvular  lesions  take  place  in  the  walls 
of  the  heart.  These  changes  are  represented  by  varying  degrees  of  hy- 
~pertrophy  or  dilatation  according  to  the  degree  and  duration  of  the  valvu- 
lar lesions  and  to  the  extent  to  which  compensation  has  been  interfered 
with.  In  the  order  of  their  frequency  the  mitral  valve  is  most  often 
affected,  next  the  aortic,  then  the  tricuspid,  and  very  rarely  the  pulmonary 
valve.  It  is  not  uncommon  for  the  aortic  and  mitral  valves  to  be  affected 
together.     In  very  rare  cases  all  the  valves  may  be  involved. 

General  Symptoms. — ^The  symptoms  of  chronic  endocarditis  develop 
gradually,  especially  when  compensatory  hypertrophy  is  complete.  They 
often  extend  over  a  period  of  many  months,  corresponding  to  the  slow 
progressive  nature  of  the  valvular  lesions.  When  there  is  a  leakage 
through  the  valves  or  when  there  is  obstruction  to  the  flow  of  blood  an 
increased  amount  of  work  is  thrown  upon  the  auricles  and  ventricles,  and 
symptoms  of  hypertrophy  or  dilatation  result  which  are  directly  in  propor- 
tion to  the  amount  of  compensation  which  is  present.     The  final  effect, 


ACQUIRED   DISEASES   OF   THE   HEART.  741 

therefore,  of  all  valvular  lesions  is  a  failing  compensation  and  venous  stasis 
throughout  the  whole  body. 

In  children  there  may  be  long  periods  when  the  morbid  conditions  do 
not  increase  and  when,  beyond  occasional  attacks  of  dyspnoea  on  exertion, 
other  symptoms  are  not  prominent. 

Symptoms,  such  as  cough,  epistaxis,  palpitation,  and  anaemia,  are  apt  to 
appear  and  then  pass  away,  when  for  any  reason  the  child  is  debilitated. 
A  decided  failure  in  compensation  is  liable  to  arise  at  any  time  from  an 
attack  of  acute  endocarditis,  from  over-exertion,  or  from  the  presence  of 
one  of  the  infectious  diseases,  such  as  scarlet  fever  or  typhoid. 

As  compensation  fails  the  corresponding  symptoms  of  a  weak  heart 
become  more  marked.  There  are  present  some,  rarely  all,  in  young  chil- 
dren, of  the  following  symptoms :  increased  dyspnoea,  orthopnoea,  bron- 
chitis, dropsy,  beginning  in  the  feet,  enlarged  liver  and  spleen,  ascites,  renal 
congestion  with  albuminuria,  indigestion,  and,  later,  prominence  of  the 
superficial  veins,  clubbed  fingers,  and  cyanosis.  Emaciation  is  a  marked 
symptom.  There  may  be  at  any  time  during  the  course  of  the  disease 
cerebral  symptoms  such  as  fainting  and  dizziness,  and  sometimes  headache. 
These  symptoms,  even  when  extreme,  may  all  pass  away,  and  then  at 
varying  periods  of  months  or  years  return.  Death  may  take  place  from 
sudden  paralysis  of  the  heart  or  as  a  result  of  the  additional  tax  on  the 
heart  from  some  intercurrent  disease,  such  as  pneumonia  or  nephritis. 
Embolism,  with  its  resulting  paralysis  or  oedema  of  the  lungs,  may  hasten 
the  fatal  result. 

In  connection  with  these  symptoms  certain  physical  signs  of  the  heart 
itself  are  present  which  correspond  to  the  especial  valvular  lesions  which 
are  present. 

Mitral  Insufficiency. — Incompetency  of  the  mitral  valve  with  regurgi- 
tation is  the  most  common  of  all  the  valvular  lesions,  and  in  most  cases 
is  caused  by  rheumatism.  It  is  also  especially  met  with  in  chorea.  Before 
compensation  has  taken  place,  the  lesion  is  represented  by  a  systolic 
murmur  most  marked  at  the  apex,  synchronous  with  the  impulse  and 
with  the  first  sound,  which  it  may  replace,  and  transmitted  into  the  axilla 
and  back.  When  compensation  has  taken  place  there  is  an  accentuated 
pulmonic  second  sound  and  an  increased  area  of  cardiac  dulness,  corre- 
sponding at  first  to  enlargement  of  the  left  auricle  and  right  ventricle  and 
later  of  the  whole  heart.  In  this  latter  condition  there  is  not  only  an 
increase  in  the  breadth  of  the  heart,  but  also  in  its  length,  the  apex  being 
depressed  and  carried  in  varied  degrees  to  the  left  of  the  mammillary  line. 
There  may  be  bulging  of  the  precordia.  The  aortic  second  sound  is 
diminished.     The  pulse  is  duninished  in  volume  and  tension. 

As  compensation  fails  the  general  symptoms  of  a  weak  heart  appear, 
and  dilatation  predominates  over  the  hypertrophy  with  the  sequence  of 
symptoms  already  described. 

Mitral  Stenosis. — Stenosis  of  the  mitral  valve  is  usually  the  result 


742  PEDIATRICS. 

of  chronic  endocarditis.  It  develops  slowly  and  is  often  a  later  stage  of 
the  same  process  which  has  earlier  produced  mitral  regurgitation.  It 
occurs  most  commonly  in  girls,  and  many  cases  are  associated  with 
tuberculosis  of  the  lungs. 

In  the  early  part  of  the  disease  there  is  little  or  no  increase  in  the 
cardiac  dulness,  but  later  the  cardiac  area  is  increased  in  breadth  and  cor- 
responds to  an  enlarged  left  auricle  and  right  ventricle.  A  sign  which 
may  be  said  to  be  characteristic  of  mitral  stenosis  is  a  thrill,  which  on 
palpation  gives  rise  to  a  purring  sensation,  felt  at  the  apex  of  the  heart, 
just  before  and  up  to  the  time  of  the  systole,  when  it  ceases  sharply.  As 
in  mitral  regurgitation,  there  may  be  bulging  in  the  precordial  region, 
especially  to  the  left  of  the  sternum  and  within  the  mammillary  line.  The 
impulse  is  both  seen  and  felt  rather  higher  in  the  vertical  line  than  is 
normal,  and  is  due  to  the  impulse  of  the  conus  arteriosus  of  the  right 
ventricle.  A  presystolic  murmur,  rough  and  purring  in  quality,  is  heard 
in  the  mitral  area  over  a  rather  limited  space,  and  is  not  markedly  trans- 
mitted. It  begins  shortly  after  the  end  of  diastole  and  increases  with  a 
crescendo  until  systole  begins,  Avhen  it  ceases  abruptly  with  a  very  sharp 
first  sound.  The  thrill  can  sometimes  be  felt  when  no  murmur  is  heard, 
and  can  be  transmitted  into  the  axilla,  while  the  murmur  is  only  heard  in 
the  mitral  area;  in  some  cases,  however,  the  murmur  is  transmitted  into 
the  axilla.  The  second  sound  is  frequently  reduplicated,  and  this  is  an 
important  diagnostic  sign,  as  it  may  be  heard  in  some  cases  in  which  the 
murmur  is  absent.  Irregularity  in  force  and  rhythm  may  occur  at  any 
stage. 

The  pulmonic  second  sound  is  accentuated,  may  be  reduphcated,  and 
may  be  transmitted  a  considerable  distance  to  the  left.  In  uncomplicated 
cases  there  is  usually  no  murmur  heard  in  the  aortic  area.  In  the  later 
stages  of  the  disease,  corresponding  to  marked  dilatation  of  the  right 
ventricle,  tricuspid  regurgitation  develops  and  the  murmur  may  disappear. 
The  sharp  first  sound  remains,  and,  with  prolongation  of  diastole  and 
great  cardiac  irregularity,  is  of  much  aid  in  the  diagnosis  at  this  stage. 
When  in  conjunction  with  a  reduplicated  second  sound,  it  suggests  mitral 
stenosis,  which  may  be  masked  by  the  prominence  of  the  signs  of  mitral 
regurgitation,  which  is  so  commonly  associated  with  mitral  stenosis. 

It  is  rather  characteristic  of  mitral  stenosis  that,  although  the  pulse 
may  be  markedly  irregular,  the  general  circulation  remains  good  for  long 
periods.  Embolism  is  a  very  common  complication,  even  more  so  than 
in  lesions  of  the  other  valves.     Haemoptysis  is  also  apt  to  occur. 

Finally,  compensation  fails  and  the  symptoms  are  the  same  as  m  mitral 
msufficiency  with  cardiac  dilatation.  Dropsy  in  many  cases  is  absent. 
Hepatic  enlargement  and  ascites  are  common.  The  increased  area  of 
cardiac  dulness  is  often  masked  by  the  increased  size  of  the  lungs. 

The  prognosis  of  pulmonary  and  pleural  affections  arising  in  the  course 
of  a  mitral  stenosis  is  especially  bad. 


ACQUIRED    DISEASES   OF   THE   HEART.  743 

A  presystolic  murmur  at  the  apex  may  }3e  heard  m  some  cases  of 
aortic  regurgitation,  but  the  murmur  may  be  considered  to  arise  from 
mitral  stenosis  if  with  absence  of  a  predominating  hypertrophy  of  the  left 
ventricle  there  are  the  signs  of  pulmonary  congestion,  accentuation  of  the 
pulmonic  second  sound,  and  a  sharp  mitral  first  sound.  Tricuspid  ob- 
struction is  almost  impossible  to  differentiate  from  mitral  stenosis,  but 
is  exceedingly  rare.  Following  an  attack  of  pericarditis  a  murmur  may 
be  heard  which  closely  simulates  mitral  stenosis,  but  is  differentiated  by 
absence  of  the  sharp  first  sound  at  the  apex  and  the  other  signs  of  peri- 
carditis. 

Aortic  Insufficiency. — Lesions  of  the  aortic  orifice  are  rare  in  child- 
hood, as  rheumatism,  the  most  frequent  cause  of  endocarditis  in  children, 
in  almost  all  cases  attacks  the  mitral  valves.  Aortic  disease  may  there- 
fore be  said  to  belong  essentially  to  a  later  period  of  life,  and,  when  it 
does  occur  in  early  life,  to  be  associated  almost  invariably  with  some 
other  valvular  lesion,  usually  the  mitral.  In  most  cases  there  is  a  thick- 
ening and  shortening  of  the  cusps,  causing  a  regurgitation  of  the  blood 
from  the  aorta  into  the  left  ventricle  during  diastole.  As  a  result  of  the 
increased  amount  of  work  thrown  on  the  left  ventricle  dilatation  and 
hypertrophy  occur,  producing  greater  ventricular  enlargement  than  any 
other  form  of  valvular  disease.  As  a  result  there  is  marked  heaving, 
throbbing,  and  often  bulging  in  the  precordia.  There  is  great  increase  of 
the  cardiac  dulness,  especially  to  the  left  and  downward. 

Aortic  insufficiency  is  shown  by  a  rather  faint  murmur  coincident  with 
or  replacing  the  second  aortic  sound.  The  maximum  intensity  of  this 
murmur  seems  to  vary  in  different  cases.  It  may  be  loudest  in  the  aortic 
area,  but  is  most  common  in  the  midsternal  region,  especially  on  the  left 
side  of  the  sternum  at  about  the  level  of  the  fourth  left  costal  cartilage. 
The  murmur  in  some  cases  is  also  heard  distinctly  near  the  apex  of  the 
heart,  and  less  frequently  its  maximum  intensity  may  be  at  the  second  or 
third  left  costal  cartilage  or  over  the  ensiform  cartilage. 

Although  in  a  certain  number  of  cases  the  murmur  may  be  transmitted 
into  the  axilla  and  even  into  the  back,  as  a  rule  the  transmission  is  limited 
to  the  precordia,  although  it  may  extend  in  all  directions,  but  especially 
downward  towards  the  apex.  The  aortic  sounds,  and  sometimes  the 
murmur,  may  be  transmitted  into  the  carotid  and  subclavian  arteries. 
The  carotid  arteries  may  show  evident  pulsation,  and  there  is  the  char- 
acteristic Corrigan  pulse.  The  first  sound  of  the  heart  at  the  apex  is 
prolonged.  The  pulmonic  second  sound  is  not  accentuated.  The  gen- 
eral symptoms  usually  come  on  slowly,  and  are  characterized  at  first  by 
dyspnoea,  headache,  and  other  signs  of  cerebral  congestion. 

Compensation  may  last  for  long  periods,  but  when  it  fails  symptoms 
of  faintness,  precordial  pain,  angina  pectoris,  and  sometimes,  although 
rarely,  dropsy  and  cyanosis  appear,  these  latter  two  symptoms  usually 
occurring  when  an  associated  relative  insufficiency  of  the  mitral  orifice 


744  PEDIATRICS. 

has  taken  place.     Death  follows  quite  frequently  from  cardiac  paralysis, 
cerebral  hemorrhage,  or  arterial  embolism  before  insufficiency  occurs. 

Aortic  Stenosis. — Narrowing  of  the  aortic  orifice  is  rare,  and  is  much 
less  frequent  than  the  other  valvular  lesions  of  the  left  side  of  the  heart. 
It  is  very  apt  to  be  associated  with  aortic  insufficiency.  As  a  result  of 
this  lesion  there  is  dilatation  and  hypertrophy  of  the  left  ventricle ;  the 
hypertrophy,  however,  being  markedly  predominant. 

Aortic  stenosis  is  represented  by  a  loud,  late,  systolic  murmur,  heard 
with  greatest  intensity  in  the  second  right  intercostal  space  and  transmitted 
upward  to  the  carotids.  The  murmur  is  also  transmitted  widely  all  over 
the  chest.  The  aortic  first  sound  is  usually  obliterated,  the  aortic  second 
is  much  weakened,  and,  if  there  is  also  an  insufficiency  of  the  aortic  valves, 
a  diastolic  murmur  is  heard. 

The  pulse  is  small,  slow,  and  wavy,  unless  modified  by  insufficiency. 
Usually  a  thrill  is  heard  and  felt  most  distinctly  in  the  aortic  area  and 
transmitted  to  the  carotids.  There  are  fewer  general  symptoms  in  this 
lesion  of  the  heart  than  in  any  other,  until  the  compensation,  Avhich  is 
usually  complete,  gives  way.  When,  however,  compensation  fails,  the 
same  genial  symptoms  which  have  been  described  under  aortic  insuffi- 
ciency occur.  Eventually  insufficiency  of  the  mitral  valve  develops,  with 
its  concomitant  signs  and  symptoms. 

It  is  to  be  remembered  that  a  systolic  murmur  in  the  aortic  area  is 
not  distinctive  of  aortic  stenosis,  and  also  that  an  aortic  systolic  murmur 
may  occasionally  be  heard  with  greatest  intensity  at  the  apex  and  be 
mistaken  for  that  of  mitral  regurgitation.  Other  murmurs  which  may 
occur  in  the  aortic  area,  and  which  are  especially  to  be  differentiated,  are 
the  functional  murmurs  of  unusual  distribution  and  the  murmur  of  the 
very  rare  pulmonary  stenosis.  A  patent  ductus  arteriosus  may  also  pro- 
duce a  systolic  murmur  in  the  aortic  area. 

Tricuspid  InsuflBciency. — Endocarditis  of  the  tricuspid  valve  acquired 
in  extra-uterine  life  is  very  rare,  and  when  it  occurs  is  associated  with 
^^4€sions  of  the  mitral  or  aortic  valves  or  of  both.  Relative  insufficiency 
of  the  tricuspid  valve  from  stretching  of  the  orifice  occurs  commonly  as  a 
result  of  mitral  insufficiency  and  of  such  pulmonary  diseases  as  emphysema 
and  chronic  bronchitis,  which  cause  obstruction  to  the  pulmonary  circulation. 

The  chief  signs  of  the  regurgitation  of  the  blood  from  the  right  ven- 
tricle into  the  right  auricle  are  as  follows.  There  is  a  Avave  of  trans- 
mission which  gives  a  systolic  pulsation  of  the  jugular  veins,  causing  them 
to  stand  out  prominently,  especially  on  the  right  side.  This  systolic 
pulsation  may  also  occur,  although  less  frequently,  in  the  liver  from  con- 
gestion of  the  branches  of  the  hepatic  vein.  There  is  a  systolic  murmur, 
rather  soft  and  low,  heard  at  the  lower  part  of  the  sternum,  the  maxi- 
mum intensity  being  near  the  sternal  junction  of  the  fifth  or  sixth  left 
costal  cartilage,  usually  not  distributed  widely,  but  in  some  cases  trans- 
mitted to  the  right  as  far  as  the  axilla.     The  pulmonic  second  sound  isj 


ACQUIRED   DISEASES   OF   THE    HEART.  745 

as  a  rule,  not  increased.  The  area  of  cardiac  dulness  corresponds  to  that 
of  dilatation  of  the  right  ventricle,  but  is  usually  moderate,  and  extends 
to  the  right  as  well  as  to  the  left  and  downward.  Cyanosis  is  especially 
pronounced. 

It  must  be  remembered  that  tricuspid  insufficiency  is  in  most  cases 
exceedingly  difficult  to  diagnosticate  :  in  some  cases  there  are  no  physical 
signs  recognizable  during  life ;  in  many  cases  the  signs  are  those  of  the 
associated  mitral  lesion,  and  the  pulmonic  second  sound  remains  strong 
even  when  a  tricuspid  lesion  is  found  to  be  present. 

Tricuspid  Stenosis. — Tricuspid  stenosis  as  an  acquired  disease  in 
extra-uterine  life  is  so  very  rare  in  children,  so  ujiiformly  of  congenital 
origin,  and  so  very  difficult  of  diagnosis,  that  it  need  only  be  referred  to  as 
a  possible  condition.  Its  diagnosis  would  depend  on  an  enlarged  right 
auricle,  a  presystolic  murmur  loudest  near  the  ensiform  cartilage,  and 
venous  congestion  as  in  tricuspid  insufficiency.  Its  frequent  association 
with  aortic  and  mitral  stenosis  makes  its  recognition,  however,  during  life 
almost  impossible. 

Pulmonary  Insuflaciency  and  Stenosis. — Although  organic  disease 
of  the  pulmonary  valve  may  result  from  foetal  endocarditis,  it  is  rarely 
acquired  in  extra-uterine  life,  and  then  only  in  septic  processes. 

The  diastolic  murmur  of  pulmonary  insufficiency  should  be  distin- 
guished from  that  of  aortic  insufficiency  by  not  being  transmitted  to  the 
carotids,  by  an  hypertrophied  right  ventricle,  by  sharp  accentuation  of 
the  pulmonic  second  sound,  by  evidence  of  septic  embolism  in  the  lungs, 
and  by  the  absence  of  the  Corrigan  pulse. 

When  there  is  pulmonary  stenosis  the  lesion  is  so  universally  of  con- 
genital origin  that  its  diagnosis  can  be  referred  to  what  has  already  been 
described  under  congenital  diseases  of  the  heart. 

Diagnosis. — The  diagnosis  of  chronic  valvular  disease,  when  a  single 
lesion  of  regurgitation  or  stenosis  is  present  without  an  association  Avith 
lesions  of  other  valves,  is  made  by  the  physical  signs  of  the  individual 
affection  which  have  just  been  described.  Combined  valvular  lesions 
are,  however,  exceedingly  common,  and  render  the  diagnosis  much  more 
difficult.  The  diagnosis  depends  upon  the  character  of  the  murmurs, 
upon  the  degree  of  dilatation  and  hypertrophy  of  the  auricles  and  ven- 
tricles, and  upon  the  general  symptoms  referable  to  the  circulation  and 
respiration.  Too  much  importance  must  not  be  attached  to  the  pres- 
ence or  sound  of  murmurs  alone,  as  they  may  be  functional.  The  dis- 
tinction between  organic  and  functional  murmurs  is  given  on  page  748. 

Prognosis. — Although  children  often  show  a  wonderful  power  of  re- 
cuperation, yet,  unless  the  lesion  is  very  slight,  it  can  never  be  completely 
recovered  from.  The  dangers  from  embolism  or  a  recurrent  endocarditis 
must  always  be  borne  in  mind  as  increasing  the  gravity  of  the  prognosis, 
but  so  long  as  compensation  is  efficient  the  prognosis  is  good,  although 
murmurs  of  all  kinds  may  be  present. 


746  PEDIATRICS, 

Many  of  the  influences  which  make  the  prognosis  in  later  life  bad, 
such  as  disease  of  the  coronary  arteries,  are  rare  in  early  life.  The  mitral 
and  aortic  valves  which  are  most  commonly  attacked  in  the  acquired  en- 
docarditis of  children  are  the  ones  in  which  compensation  is  most  readily 
attained.  In  young  children,  however,  the  prognosis,  on  the  whole,  is 
unfavorable  in  chronic  valvular  lesions. 

The  nutrition  of  the  rapidly  growing  heart  is  easily  affected,  and  dila- 
tation develops  rapidly.  Recurrent  attacks  of  rheumatism  are  very 
common  in  children,  and  each  attack  increases  the  gravity  of  the  prog- 
nosis. In  like  manner  the  onset  of  one  of  the  acute  infectious  diseases 
means  an  exceptionally  bad  prognosis  in  children  in  whom  valvular  dis- 
ease is  present. 

Extensive  pericardial  adhesions,  insufficient  or  improper  food,  a,nd 
lack  of  supervision  of  the  amount  of  exercise  greatly  increase  the  risks  of 
disturbing  the  compensation  of  the  heart. 

Treatment  of  Chronic  Endocarditis. — The  indications  for  treatment 
of  chronic  endocarditis  depend  less  upon  the  character  of  the  lesion  than 
upon  the  degree  of  compensation  which  is  present.  When  compensation 
is  established  and  withstands  the  ordinary  demands  of  life,  hygienic  and 
prophylactic  measures  alone  are  necessary.  As  compensation  fails,  active 
treatment  is  called  for,  and  is  directly  proportionate  to  the  severity  of  the 
symptoms. 

Simple  hypertrophy  of  the  heart,  therefore,  whether  from  endocardial 
causes,  as  from  chronic  valvular  lesions,  or  from  exocardial  conditions, 
does  not  require  the  use  of  drugs.  The  regulation  of  the  habits  of  life 
are  of  the  first  importance.  Great  care  should  be  taken  not  to  overtax 
any  of  the  functions  of  the  body.  The  digestive,  nervous,  and  muscular 
systems  should  be  kept  well  within  the  limits  of  fatigue.  The  diet  should 
be  carefully  regulated  according  to  the  age  and  digestion  of  the  child. 
Nervous  strain  from  over-study  and  emotional  excitement  should  be  care- 
fully guarded  against.  Out-of-door  life  and  moderate  exercise  should  be 
^ — -encouraged,  but  the  more  vigorous  forms  of  athletic  sports  should  be  pro- 
hibited. Each  case  must  be  judged  by  itself  as  to  the  amount  of  muscu- 
lar work  which  is  permissible,  and  this  can  be  determined  only  by  begin- 
ning Avith  the  mildest  forms  of  exercise  and  cautiously  increasing  the 
amount.  It  is  often  desirable  to  insist  upon  absolute  rest  in  bed  or  on  a 
lounge  for  an  hour  or  two  in  the  middle  of  each  day. 

With  the  advent  of  the  early  symptoms  of  failing  compensation  the 
cessation  of  all  exercise  and  the  use  of  appropriate  doses  of  nux  vomica 
and  iron  for  a  few  weeks  may  restore  the  lost  compensation.  If  the 
symptoms  are  persistent,  the  nux  vomica  should  be  supplanted  by  small 
doses  of  the  tincture  of  digitalis,  A  change  of  climate  is  sometimes  to 
be  recommended  in  those  cases  in  which  the  failure  of  compensation  is 
slowly  progressive. 

Acute  dilatation  may  come  on  suddenly  with  but  few  premonitory 


ACQUIRED   DISEASES    OF   THE    HEART.  747 

symptoms.  The  treatment  is  then  absolute  rest  in  bed  and  active  stimu- 
lation by  the  use  of  strychnine  and  digitalis  in  doses  as  recommended  on 
page  464.  Brandy  or  aromatic  spirits  of  ammonia  are  useful  to  bridge 
over  a  crisis,  and  not  infrequently  small  doses  of  morphine,  guarded  with 
atropine,  given  subcutaneously,  can  advantageously  precede  the  use  of 
the  cardiac  stimulants.  Digitalis  and  strychnine  are,  however,  the  drugs 
on  which  most  reliance  can  be  placed  in  all  the  stages  of  a  broken  com- 
pensation. As  the  cardiac  weakness  increases,  special  symptoms  arise 
which  demand  special  treatment. 

Dyspnoea. — When  the  dyspnoea  becomes  troublesome,  the  child  should 
be  propped  up  by  means  of  pillows  or  a  bed-rest  into  a  semi-upright 
position.  The  cause  of  the  dyspnoea  should  be  determmed  if  possible, 
remembermg  that  it  may  be  due  to  flatulency,  hydrothorax,  hydroperi- 
cardium,  ascites,  or  oedema  of  the  lungs.  If  it  is  of  gastric  origin,  the 
digestive  disturbance  should  receive  appropriate  treatment,  both  for  the 
relief  of  the  immediate  symptoms  and  the  prevention  of  its  recurrence  by 
the  proper  change  in  the  diet.  Hydrothorax,  if  present,  may  require  re- 
peated tapping,  but  this  is  of  rare  occurrence.  The  oedema  of  the  lung, 
as  evidenced  by  the  dyspnoea,  cough,  and  physical  signs,  is  best  controlled 
by  stimulation  of  the  heart  rather  than  by  treatment  directed  to  the  lungs. 
When  the  dyspnosa  is  apparently  due  to  high  blood-tension,  the  use  of 
nitroglycerin,  in  doses  such  as  are  prescribed  on  page  464,  will  often 
meet  the  requirements. 

Vomiting. — Vomiting  is  often  a  difficult  symptom  to  control.  If  it  is 
due  to  venous  stasis,  digitalis  will  often  act  well,  but  the  vomiting  may  in 
itself  be  an  early  indication  of  the  over-action  of  digitalis.  If  the  vomit- 
ing is  persistent,  it  may  be  necessary  to  omit  all  food  by  the  stomach. 
Cracked  ice  in  some  simple  charged  water,  or  in  champagne,  or  in  milk 
and  lime-w^ater,  can  be  used  until  stronger  food  is  tolerated. 

Dropsy. — The  successful  treatment  of  dropsy  depends  upon  the  re- 
cuperative power  which  remains  in  the  heart.  Digitalis  is  of  the  utmost  use, 
and  should  be  given  in  sufficiently  large  doses  to  produce  a  decided  effect, 
but  with  careful  attention  to  its  physiological  action.  Its  diuretic  proper- 
ties may  be  increased  at  times  by  giving  it  with  small  doses  of  calomel 
and  caffeine,  providing  the  kidneys  show  the  evidence  only  of  passive 
congestion.  Saline  cathartics  can  be  given  to  diminish  the  oedema  by  de- 
pletion. It  is  often  desirable  to  promote  catharsis  and  diuresis  on  alter- 
nate days.  If  ascites  or  hydrothorax  is  excessive,  the  fluid  should  be 
aspirated  at  once,  as  delay  may  prove  serious.  The  quantity  of  urine 
should  be  carefully  noted  when  digitalis  is  being  given.  An  increase  in 
the  quantity  should  follow  its  administration.  When  the  urine  diminishes 
steadily  in  spite  of  the  digitalis,  we  should  watch  carefully  for  other 
symptoms  of  the  cumulative  action  of  the  drug.  Diuretin  in  doses  of 
0.3  to  0.6  gramme  (5  to  10  grains)  is  a  valuable  diuretic  in  all  forms  of 
cardiac  dropsy,  and  may  be  given  alone  or  with  digitalis. 


748  PEDIATRirS. 

Nervous  Symptoms. — Tlie  nervous  symptoms  of  restlessness  and  in- 
somnia may,  if  moderate  in  degree,  be  controlled  by  trional  or  the  bro- 
mides, 0.12  to  0.3  gramme  (2  to  5  grains);  more  frequently  they  require 
the  use  of  morphine  combined  with  atropine,  which  are  the  most  effective 
remedies  we  have,  but  require  good  judgment  in  their  use. 

Finally,  it  is  of  the  greatest  importance  that  a  child  with  a  chronic 
valvular  lesion  of  the  heart  should  be  kept  under  medical  supervision 
even  during  the  intervals  of  complete  compensation.  By  doing  this  we 
are  frequently  able  to  detect  changes  in  the  condition  of  the  heart  before 
the  mother  herself  becomes  aware  of  them,  and  by  attention  to  the  prin- 
ciples already  outlined  we  may  often  avert  the  serious  consequences  which 
follow  neglect  of  treatment. 

FUNCTIONAL  DISEASES  OF  THE  HEART. 

By  functional  disease  of  the  heart  we  mean  that  there  are  no  patho- 
logical conditions  present  beyond  a  weakness  of  the  cardiac  muscles  and 
possibly,  in  some  cases,  a  slight  degree  of  dilatation  of  the  cavities.  It  is 
a  condition,  therefore,  represented  by  symptoms  rather  than  by  physical 
signs,  with  the  exception  that  in  many  cases  cardiac  murmurs  are  present. 
It  is  rare  to  meet  with  functional  cardiac  disturbances  before  the  middle 
.  period  of  childhood,  but  they  increase  in  frequency  as  puberty  is  ap- 
proached. 

Etiology. — Functional  cardiac  disturbance  may  occur  in  the  course  of 
such  neuroses  as  exophthalmic  goitre.  Again,  it  may  arise  from  poor  food 
and  hygiene,  from  a  lack  of  sufficient  out-of-door  exercise,  and  from  over- 
strain in  school  life,  leading  to  malnutrition  with  nervous  exhaustion.  It 
may  also  result  from  the  use  of  such  cardiac  irritants  as  tea  and  coffee, 
and  may  follow  or  occur  in  the  course  of  any  of  the  acute  diseases.  The 
various  forms  of  anaemia  may  produce  functional  murmurs,  known  as 
hwmic  murmurs. 

Symptoms. — The  chief  symptoms  are  palpitation,  a  weakened,  irregular 
X^^ulse,  attacks  of  dyspnoea  and  fainting,  and  cardiac  murmurs.  These 
attacks  occur  in  paroxysms  and  are  not  associated  with  the  physical 
signs  of  organic  cardiac  disease. 

Of  especial  interest  are  the  cardiac  murmurs  of  functional  origin,  as 
they  simulate  closely  and  must  be  differentiated  from  organic  murmurs, 
whether  congenital  or  acquired.  These  functional  or,  as  they  are  some- 
times called,  hasmic  nmrmurs  are  variable  in  character  according  to  the 
position  of  the  child,  and  may  sometimes  be  intensified  by  the  pressure  of 
the  stethoscope. 

According  to  Jacobi,  Steffen,  and  Hochsinger  they  may  also  be  caused 
by  the  irritation  resulting  from  deformity  of  the  thorax  such  as  occurs  in 
rhachitis. 

Diagnosis. — In  the  great  majority  of  cases  functional  murmurs  are  sys- 
tolic, soft,  though  they  may  be  very  loud,  and  are  heard  best  in  the  pul- 


ACQUIRED   DISEASES    OF   THE    HEART.  749 

monic  area.  They  are  apt  to  be  associated  with  anaemia,  are  evanescent, 
are  not  connected  with  cardiac  enlargement,  and  are  not  accompanied  by 
an  accentuated  puhnonic  second  sound  or  by  general  systemic  venous 
engorgement. 

While  these  functional  murmurs  may  be  transmitted  in  all  directions, 
and  are  often  associated  with  loud  bruits  in  the  vessels  of  the  neck,  yet, 
as  a  rule,  they  do  not  show  their  maximum  intensity  at  the  heart's  apex  and 
are  not  transmitted  distinctly  to  the  axilla  and  back.  The  systolic  mur- 
murs heard  occasionally  over  the  anterior  fontanelle  in  infants  are  probably 
arterial. 

In  contradistinction  to  functional  murmurs,  organic  murmurs  are  usually 
rougher  and  more  musical,  are  distinctly  transmitted  to  the  great  vessels 
of  the  neck  or  to  the  axilla  and  back,  may  be  heard  with  maximum  in- 
tensity over  any  part  of  the  cardiac  area  corresponding  to  the  various 
valves,  are  rarely  loudest  in  the  pulmonic  area,  and  are  usually  associated 
with  an  enlarged  cardiac  area,  accentuated  pulmonic  second  sound,  and  in 
many  cases  with  general  signs  of  systemic  stasis,  such  as  cough,  haemop- 
tysis, oedema  of  the  lungs  and  extremities,  ascites,  and  cyanosis. 

Prognosis. — The  prognosis  in  the  cases  in  which  there  is  no  organic 
disease  of  other  organs,  or  when  the  disease  in  which  they  occur  is  be- 
nign, is  exceedingly  good,  provided  that  the  appropriate  treatment  is  rigidly 
carried  out. 

Treatment. — During  the  attack  mild  stimulants,  such  as  aromatic  spirits 
of  ammonia,  should  be  given,  and  if  there  is  a  strong  nervous  element  the 
bromides.  In  prolonged  attacks  digitalis  in  small  doses  is  indicated,  and 
in  some  cases  strychnine. 

When  a  cause  can  be  detected,  such  as  anaemia,  it  should  be  treated 
with  iron  or  arsenic.  When  no  especial  cause  can  be  found,  all  cardiac 
irritants  should  be  avoided  and  careful  directions  given  as  to  study,  exer- 
cise, diet,  and  general  hygiene. 

The  following  case  was  one  of  primary  malignant  endocarditis  with 
secondary  infection  of  the  pericardium,  mediastinum,  veins,  lungs,  pleurae, 
and  spleen. 

A  boy,  four  years  old,  was  attacked  one  month  previously  with  fever,  thirst,  and 
pain  in  his  knees.  Later  his  feet  became  painful  and  swollen,  and  other  joints  were 
successively  involved.  He  complained  of  pain  in  the  back  of  his  neck  and  along  his 
spine.  One  week  before  entering  the  hospital  he  began  to  have  moderate  but  inces- 
sant choreic  movements,  and  showed  much  incoordination  of  mastication  and  articu- 
lation. 

A  physical  examination  showed  the  lungs  to  be  normal,  the  area  of  cardiac  dul- 
ness  somewhat  increased  to  the  left  of  the  mammillary  line,  and  a  systolic  murmur  at 
the  apex,  transmitted  into  the  axilla  and  back.  On  the  following  day  a  pericardial 
friction-sound  was  heard  just  above  the  left  nipple,  accompanied  by  precordial  pain. 
Two  weeks  later  the  choreic  symptoms  disappeared,  and  the  temperature  became 
normal.  The  area  of  cardiac  dulness  did  not  extend  under  the  sternum,  but  was 
found  to  correspond  to  the  impulse  of  the  heart,  which  was  1.4  cm.  (J  inch)  outside 


750 


PEDIATRICS. 


of  the  left  mammillary  line.  During  the  last  week  of  its  life  the  child  became  very 
weak,  had  marked  dyspnoea,  and  showed  signs  of  effusion  in  the  right  pleural  cavity, 
but  presented  no  other  symptoms. 

The  post-mortem  examination  showed  that  both  pleural  cavities  contained  consid- 
erable blood-stained  fluid,  in  some  places  there  were  adhesions  of  the  parietal  and 
visceral  layers,  in  others  there  was  slight  fibrinous  exudation  over  the  surfaces  of  the 
lungs.  On  section  both  lungs  showed  congestion  and  areas  of  broncho-pneumonia.  The 
anterior  mediastinum  was  injected,  and  some  of  the  mediastinal  glands  were  enlarged. 
The  parietal  layers  of  the  pericardium  and  pleurae  were  adherent  and  thickened.  The 
heart  was  enlarged,  and  in  places  the  myocardium  was  distinctly  soft  and  pale.  Along 
the  free  border  of  the  right  auriculo-ventricular  valve  there  were  a  few  fresh  vegeta- 
tions. The  left  side  of  the  heart  was  dilated.  The  edge  of  the  mitral  valve  was  thick- 
ened and  eroded.  Small,  whitish  points  could  be  seen  beneath  the  endocardium,  both 
on  the  walls  and  on  the  papillary  muscles.  The  aortic  valves  showed  a  few  fibrinous 
deposits  at  the  edges  of  contact.     The  coronary  arteries  were  normal. 

The  spleen  and  lymph-glands  were  enlarged  and  soft.  The  liver  showed  congestion. 
In  the  left  jugular  vein  was  found  an  adlierent  thrombus  which  extended  down  into 
the  subclavian  vein,  the  innominate  vein,  and  the  superior  vena  cava,  completely 
obliterating  them. 

Microscopic  examinations  showed  the  infection  to  be  due  to  streptococci  and  the 
vegetations  on  the  mitral  valve  to  be  distinctly  vei'rucose.  Pure  cultures  of  streptococci 
were  obtained  from  the  lungs,  pericardium,  bronchial  lymph-glands,  and  spleen  ;  the 
other  organs  were  sterile. 

Dr.  Councilman,  who  performed  the  autopsy,  considered  the  endocarditis  primary 
and  of  the  malignant  type,  with  a  secondary  infection  of  the  lung.  The  mode  of  in- 
fection was  probably  from  the  heart  to  the  pericardium,  thence  to  the  mediastinum, 
with  thrombosis  of  the  veins,  from  which  the  infection  was  carried  to  the  lungs,  setting 
up  a  broncho-pneumonia,  which  in  its  gross  and  microscopic  appearances  differed 
from  the  ordinary  broncho-pneumonia  of  infants. 

The  next  case  illustrates  simple  acute  endocarditis,  followed  by  dila- 
tation of  the  heart  and  loss  of  compensation. 

Fig.    153. 


Acute  endocarditis.    Mitral  insufficiency.    Lack  of  compensation.     Orthopncea.    Female.  'J  years  old. 


The  child  was  nine  years  old,  and  although  she  had  always  been  delicate  she  had 
never  had  any  especial  disease  until  two  weeks  previously,  when  she  was  attacked 


ACQUIRED    DISEASES   OF   THE   HEART.  751 

with  fever,  palpitation,  cough,  and  a  rapid,  irregular  pulse.  On  entering  the  hospital 
she  was  cyanotic,  the  face  and  extremities  were  cold,  and  there  was  considerable  promi- 
nence over  the  cardiac  region.  The  resonance  of  the  lungs  was  normal,  but  there 
were  a  few  moist  rales  at  both  bases.  The  impulse  of  the  heart  was  in  the  fifth  left 
interspace,  1.4  cm.  (J  inch)  outside  of  the  mammillary  line,  and  there  was  a  marked 
thrill  with  a  systolic  murmur  transmitted  into  the  axilla  and  heard  distinctly  in  the 
back.  The  liver  was  slightly  enlarged.  The  temperature  during  the  acute  inflamma- 
tory stage  of  the  endocarditis  was  moderately  elevated,  reaching  38.8°  C.  (102°  F.)  on 
the  fourth  day,  and  gradually  subsiding. 

The  impulse  of  the  heart  Avas  scarcely  perceptible.  The  area  of  cardiac  dulness 
extended  to  the  right  edge  of  the  sternum,  and  slightly  beyond  the  right  sternal  line 
beneath  the  third  intercostal  space. 

The  case  illustrates  an  attack  of  acute  endocarditis,  either  primary  in  character  or 
more  probably  ingrafted  upon  a  chronic  endocarditis,  which  had  never  given  rise  to 
symptoms,  as  the  limits  of  compensation  had  never  before  been  disturbed.  The  acute 
inflammatory  stage  passed  ;  dilatation  took  place,  and  there  was  marked  failure  of 
compensation,  shown  by  the  feeble  impulse  of  the  heart,  the  weak  and  fluttering 
pulse,  the  cold  and  blue  extremities,  the  orthopnoea,  and  the  tendency  to  oedema  of 
the  face,  legs,  and  feet.  Fig.  153  represents  the  position  which  the  child  assumed  on 
her  right  side,  supporting  herself  with  her  arms,  and  shows  her  anxious  expression  as 
she  endeavored  to  keep  herself  in  a  position  in  which  she  could  breathe  easily. 

The  following  case  illustrates  the  condition  of  pure  mitral  stenosis, 
with  periods  of  broken  compensation  alternating  with  periods  of  re- 
established compensation : 

The  boy,  who  was  eleven  years  old.  had  measles  when  he  was  an  infant,  diph- 
theria when  he  was  three  years  old,  and  pertussis  when  he  was  four  years  old.  He 
had  always  been  well  until  he  was  nine  and  a  half  years  old,  when,  after  indefinite 
pains  in  his  joints,  accompanied  by  no  swelling  and  not  sufficiently  severe  to  confine 
him  to  bed,  he  began  to  have  dyspnoea  on  exertion,  and  cardiac  pain,  cough,  cyanosis, 
and  considerable  loss  of  weight.  An  examination  of  the  heart  showed  the  area  of 
absolute  dulness  to  be  decidedly  increased  to  the  left.  A  loud  presystolic  murmur  was 
heard  at  the  apex,  limited  in  its  extent  and  accompanied  by  a  thrill  and  a  sharp  first 
sound.  There  was  no  systolic  murmur  and  no  oedema.  The  physical  examination 
showed  nothing  else  of  significance. 

In  the  course  of  two  months'  treatment  compensation  was  established,  but  the 
boy  returned  to  the  hospital  from  time  to  time  with  the  same  symptoms  which  have 
been  described. 

In  the  next  case,  in  contrast  to  the  one  just  given,  we  see  the  symp- 
toms of  a  mitral  stenosis  combined  with  mitral  insufficiency. 

The  child  was  a  girl  of  thirteen  years.  When  eleven  years  of  age  she  had  an 
attack  of  rheumatic  fever  followed  by  dyspnoea  on  exertion,  and  at  times  oedema  of  the 
feet.  A  week  before  we  saw  her  she  was  taken  with  pain  in  the  region  of  the  heart, 
so  severe  that  she  could  not  sleep.  On  entrance  to  the  hospital  her  temperature  was 
38.5°  C.  (101.2°  F.),  her  pulse  104,  and  her  respirations  65.  The  physical  exami- 
nation showed  the  apex-beat  to  be  in  the  fifth  interspace  in  the  mammillary  line.  The 
area  of  cardiac  dulness  was  enlarged,  extending  to  the  upper  border  of  the  third  rib 
and  about  5.3  cm.  (2  inches)  to  the  left  of  the  mammillary  line,  and  about  a  finger's 
breadth  to  the  right  of  the  right  border  of  the  sternum.  A  presystolic  murmur  was 
heard  at  the  apex  and  was  confined  to  a  limited  area,  while  a  systolic  murmur,  osal 


752  PEDIATRICS. 

heard  at  the  apex,  was  transmitted  to  the  axilla  and  back.  The  pulmonic  second 
sound  was  accentuated.  In  this  respect  the  physical  signs  were  negative,  as,  in  spite 
of  the  marked  hypertrophy  and  dilatation  of  the  heart,  compensation  of  the  right  heart 
was  sufficient  to  prevent  the  results  of  venous  stasis. 

Pour  weeks  later,  after  being  treated  by  complete  rest  in  bed,  the  cardiac  symptoms 
almost  entirely  disappeared,  the  area  of  cardiac  dulness  was  much  diminished,  the 
murmurs  were  less  distinct,  and  the  child  left  the  hospital  much  improved. 

The  next  case  (Fig.  154),  a  boy,  ten  years  old,  is  interesting  as  illus- 
trating several  characteristics  of  cardiac  disease  in  early  life. 

When  eight  years  old  he  entered  the  hospital  with  marked  cedema  of  the  face, 
body,  and  limbs,  ascites,  a  slight  amount  of  fluid  in  both  pleural  cavities,  and  oedema 
of  the  lungs.  There  was  no  definite  history  of  rheumatic  fever  nor  any  other  cause  for 
the  cardiac  disease  which  was  causing  these  symptoms,  and  which  had  apparently  de- 
veloped insidiously,  although  if  he  had  been  under  closer  observation  a  definite 
period  of  onset  would  probably  have  been  discovered.  The  impulse  of  the  heart  was 
found  to  be  1.4  cm.  (J  inch)  outside  of  the  mam  miliary  line  in  the  fifth  left  interspace. 
The  area  of  cardiac  dulness  was  somewhat  increased.  There  was  a  loud  systolic 
murmur  at  the  cardiac  apex  transmitted  to  the  axilla.  The  pulmonic  second  sound 
Avas  much  accentuated.  Fig.  155  was  taken  at  that  time,  and  shows  the  marked  oedema 
of  the  legs  and  the  much  distended  abdomen.  He  was  treated  by  complete  rest  in  bed 
for  five  weeks,  and  in  the  beginning  digitalis  was  administered  until  the  urine,  which 
was  lessened  in  quantity,  had  increased  and  the  oedema  of  the  lungs  had  disappeared. 
On  entering  the  hospital  the  ascites  was  removed  by  paracentesis  abdominis.  Under 
this  treatment  the  child  rapidly  improved,  the  general  cedema  disappeared,  the  liver 
returned  to  its  normal  size,  the  area  of  cardiac  dulness  was  markedly  decreased,  the 
cardiac  murmur  became  less  marked,  and  six  weeks  from  the  time  when  he  entered 
the  hospital  complete  compensation  was  established  and  he  left  the  hospital  seemingly 
perfectly  well. 

After  leaving  the  hospital  the  boy  was  reported  to  have  been  very  well,  except  that 
he  could  not  play  or  work  hard.  Two  weeks  before  his  second  entrance  he  was  attacked 
with  fever,  precordial  distress,  and  cardiac  pain  ;  later  he  began  to  have  oedema  of  the 
feet  and  dyspnoea.  From  that  time  he  grew  progressively  worse,  and  his  case  illustrates 
a  fresh  attack  of  endocarditis  supervening  on  an  old  chronic  endocarditis  (endocarditis 
recurrens)  and  resulting  in  a  disturbance  of  the  previous  compensation.  He  had  or- 
thopnoea  to  such  an  extent  that  he  was  unable  to  lie  down  in  bed,  and  had  to  be  con- 
tinually watched  by  a  nurse,  as  he  frequently  had  attacks  of  excessive  paroxysmal 
dyspnoea  which  were  liable  to  prove  fatal.  There  was  cyanosis  of  the  lips  and  hands 
and  marked  general  oedema.  The  skin  of  the  nose  and  extremities  was  cold.  The 
impulse  of  the  heart  was  felt  in  the  sixth  left  interspace  2.8  cm.  (1  inch)  beyond  the 
mammillary  line.  The  area  of  cardiac  dulness  extended  beneath  the  sternum,  and  at 
the  thii-d  intercostal  space  extended  1.4  cm.  (J  inch)  to  the  right  of  the  sternum, 
thence  upward  in  a  curved  line  across  the  upper  part  of  the  sternum  to  the  second  rib, 
and  then,  keeping  outside  of  the  mammillary  line,  descended  and  joined  the  point  of 
cardiac  impulse.  There  was  a  loud  systolic  murmur,  heard  most  distinctly  at  the  apex, 
but  transmitted  over  the  whole  cardiac  area  and  through  the  axilla  to  the  back.  The 
pulmonic  second  sound  was  accentuated.  The  aortic  sounds  were  weak.  There 
were  numerous  moist  rales  heard  in  all  parts  of  the  lungs.  The  percussion  of  the 
lungs  was  resonant  everywhere  except  in  the  lower  parts,  where  there  seemed  to  be  a 
slight  amount  of  fluid  in  both  pleural  cavities.  The  liver  was  enlarged  so  that  it  ex- 
tended 7.8  cm.  (3  inches)  below  the  margin  of  the  ribs.  Ascites  was  present,  the  fluid 
rising  to  about  the  line  of  the  umbilicus.     The  spleen  was  normal  in  size.    The  child 


Fig.  154. 


Chronic  recurrent  cmlocarditis.    Mitral  insutTiciency.     Disturbance  of  compensation.    Dilated  heart. 
Enlarged  liver.    (Edema  of  lungs.    Ascites.    JSlale,  10  years  old. 


Fn..   1 


Clnunic  endocarditis.    Mitral  insutticiency.    General  cedema  and  ascites.     (Before  treatment.) 


ACQUIRED   DISEASES   OF   THE   HEART. 


753 


vras  passing  only  a  small  amount  of  urine,  which  contained  a  trace  of  albumin.  The 
cardiac  and  hepatic  areas  of  dulness  and  the  upper  border  of  the  ascites  have  been 
marked  by  black  lines,  the  margin  of  the  ribs  by  broken  lines,  the  point  of  cardiac 
impulse  by  a  black  ring,  and  the  oedematous  rales  in.  the  chest  by  smaller  black  rings. 
The  prognosis  in  this  case,  although  very  serious,  as  he  vras  liable  to  die  suddenly  at 
any  time  if  extra  blood-pressure  should  be  brought  to  bear  upon  the  dilated  and  crip- 
pled heart,  was  not  entirely  unfavorable,  as  he  had  previously  shown  such  great  powers 
of  compensation  and  recuperation.  As  there  was  no  great  distention  of  the  abdomen, 
the  ascites  was  not  removed  by  paracentesis.  He  wras  given  infusion  of  digitalis,  3.75 
c.c.  (1  drachm),  every  three  hours,  and  diuretin,  0.36  gramme  (6  grains),  once  in  six 
hours  as  a  diuretic.      His  diet  was  milk. 

Within  fortj'-eight  hours  rapid  relief  was  obtained  from  the  urgent  symptoms,  and 
at  the  end  of  three  weeks  the  cedema  of  the  lungs,  the  general  oedema,  and  the  ascites 
had  disappeared  entirely.  The  urine  became  normal  in  quantity  and  free  from  albu- 
min. One  week  later  he  was  well  enough  to  be  out  of  bed  for  an  hour  each  day,  but 
at  that  time  the  heart  and  liver  were  still  enlarged,  as  shown  in  Fig.  156. 


Fig.  1o6. 


Fig.   157. 


Chronic  endocarditis.  Mitral  insufficiency. 
Returning  compensation.  Enlarged  liver.  En- 
larged heart. 


Chronic  endocarditis.  Mitral  insufficiency. 
Broken  line  indicates  enlarged  heart.  Black  line 
indicates  area  of  cardiac  dulness  with  returned 
and  complete  compensation. 


Some  weeks  later  the  liver  regained  its  normal  size,  and  still  later  the  cardiac  area 
of  dukiess  was  found  tp  be  much  reduced  and  in  the  vertical  line  almost  normal.  Fig. 
157  shows  the  enlarged  heart,  which  persisted  longer  than  the  enlarged  liver,  and  is 
represented  by  a  broken  line  ;  the  area  of  dulness  of  the  heart  as  it  appeared  when 
he  left  the  hospital  is  shown  by  a  black  curved  line. 


754  PEDIATRICa 

DISEASES  OF  THE  PERICARDIUM. 

The  relations  of  the  infant's  pericardium,  so  far  as  we  have  been  able 
to  determine  by  our  dissection  of  sixteen  infants  of  different  ages,  does 
not  differ  from  those  of  the  adult.  The  amount  of  fluid  wliich  normally 
occurs  in  an  mfant's  pericardium,  although  of  variable  ciuantity,  is  probably 
under  5  c.c.  Hydropericardium,  pneumopericardium,  and  hiemopericar- 
dium  are  so  very  rare  that  they  need  merely  be  referred  to. 

ACUTE    PERICARDITIS. 

Etiology. — Acute  pericarchtis  may  occur  at  any  period,  but  the  earlier 
the  age  the  less  often  is  it  met  with.  It  has  been  found  in  the  foetus  and 
in  the  new-born.  It  is  generally  the  result  of  an  infective  process,  which 
may  be  primary  or  secondary.  It  may  arise  also  as  a  result  of  direct 
''^xtension  of  an  inflammation  from  the  pleurce,  mediasthium,  and  adja- 
cent tissues. 

Various  bacteria  have  been  demonstrated  in  the  inflammatory  prod- 
ucts of  pericarchtis  and  m  the  pericardium  itself,  although  they  are  not 
always  connected  m  a  specific  manner  Avith  the  disease.  Different  kinds 
of  streptococci  and  staphylococci  are  found.  The  pneumococcus 
frequently  occurs  in  cases  followmg  pneumonia,  and  is  also  found  inde- 
pendently. Tubercle  bacilli  have  been  demonstrated  in  tul^ercular  peri- 
carditis, and  the  pericardium  shows  an  especial  tendency  to  the  mvasion 
of  this  bacillus  folloAAing  tuberculosis  of  the  pleura.  Tuberculosis  as  a 
primary  chsease  is  even  more  rare  in  the  cliild  than  in  the  adult. 

In  the  new-born,  pericarchtis  may  be  the  result  of  a  septic  condition 
following  infection  of  the  cord.  At  times  it  follows  periostitis  and  ostitis 
in  young  children,  here  also  probably  being  associated  with  septic  infec- 
tion. Traumatism  may  also  be  a  cause  of  pericarditis.  Rheumatic  fever, 
especially  after  the  third  or  fourth  year  of  life,  gives  rise  to  as  much 
pericardial  disease  as  at  a  later  period.  The  inflammatory  lesions  may 
~  arise  before  the  rheumatic  fever  has  appeared  elsewhere,  and  the  intensity 
of  the  arthritic  pain  and  the  number  of  joints  affected  do  not  correspond 
to,  or  rather  do  net  influence,  the  frequency  of  the  pericardial  compli- 
cation. Inflammation  of  the  pericardium  is  also  frequently  associated 
^^-ith  pneumonia.  It  may  be  secondary  to  any  of  the  eruptive  fevers,  but 
occurs  most  frequently  as  a  complication  of  scarlet  fever.  When  it  occurs 
in  this  latter  chsease  it  appears  usually  in  the  second  or  third  week  of  the 
attack. 

Pathological  Anatomy. — Pericarditis  may  be  circumscribed  or  diffuse, 
and  there  appears  to  be  no  essential  difference  between  the  pathological 
conditions  affecting  the  pericardium  in  early  life  and  those  which  occur  Jater. 
The  pericarditis  sicca  of  the  adult  is  comparatively  unusual  in  the  child,  in 
whom,  as  a  rule,  an  exudation  of  greater  or  less  extent  almost  always 
takes  place.     The  exudation  may  be  sero-fibrinous,  hemorrhagic,  or  puru- 


DISEASES   OF   THE   PERICARDIUM.  755 

lent.  Not  only  is  the  tendency  to  exudation  in  the  child  greater  than  in 
the  adult,  but  its  formation  is  characterized  by  greater  rapidity  and  is 
more  likely  to  be  purulent.  A  pericardial  exudation  tinged  with  blood  is 
not  uncommon  in  early  life,  and  is  not  necessarily  so  significant  of  tuber- 
culosis as  is  a  pronounced  hemorrhagic  exudation. 

Acute  Plastic  or  Dry  Pericarditis. — Symptoms. — The  symptoms  of 
acute  plastic  or  dry  pericarditis  are  often  so  mild  as  to  be  overlooked. 
There  may  be  slight  precordial  pain  and  pyrexia.  The  characteristic  physi- 
cal signs  are  represented  by  a  double  to-and-fro  murmur,  which  is  not  ex- 
actly synchronous  with  systole  and  diastole,  is  more  superficial  than  an 
endocardial  murmur,  and  is  of  a  rubbmg  or  gratmg  character.  The 
sound  is  localized  in  a  small  area,  is  not  transmitted  as  in  endocardial 
murmurs,  and  does  not  replace  the  heart-sounds.  The  murmur  is  at 
times  intensified  by  pressure  with  the  stethoscope.  These  signs,  however, 
are  of  temporary  duration,  as  a  rule,  as  the  exudation  of  fibrin  is  soon 
followed  by  that  of  fluid.  In  many  cases  in  early  life  friction-sounds 
and  endocardial  murmurs  simulate  each  other  very  closely. 

Acute  Pericarditis  with  Exudation. — Symptoms. — The  subjective 
symptoms  of  acute  pericarditis  with  exudation  in  infancy  are  very  in- 
definite, and  throughout  childhood  this  latency  of  the  early  symptoms  is 
so  marked  and  occurs  so  frec{uently  that  it  may  be  said  to  be  character- 
istic of  the  symptomatology  of  pericarditis  in  early  life.  It  is  so  difficult  to 
locate  pain  when  it  occurs  in  the  infant,  and  a  tumultuous  action  of  the 
heart  with  general  circulatory  disturbance  is  so  commonly  the  result  of  a 
diseased  condition  outside  of  this  central  organ,  that  it  is  impossible  to 
formulate  a  practical  general  symptomatology  for  the  onset  of  the  disease. 
When,  however,  the  disease  has  progressed,  dyspncEa  and  orthopnoea 
become  marked.  Large  exudations  appear  to  affect  the  functional  activity 
of  the  heart  more  rapidly  in  children  than  in  adults,  and  to  occasion  earlier 
the  signs  of  disturbance  of  the  circulation,  such  as  cyanosis  and  coldness 
of  the  nose  and  extremities.  Diminution  in  the  amount  of  the  urine, 
with  a  corresponding  increase  in  the  urine  as  the  exudation  decreases,  has 
been  noticed  in  children. 

Physical  Signs. — The  usual  physical  signs  supposed  to  be  character- 
istic of  pericarditis  are  often  very  misleading,  and  Avhen  a  pericardial 
friction-sound  is  absent  the  diagnosis  of  pericarditis  in  a  young  child  may 
present  great  difficulties. 

Inspection. — Owing  to  the  flexible  thorax  of  the  child,  there  is  a  greater 
opportunity  for  the  neighboring  parts  to  yield  before  the  pressure  of  the 
fluid,  and  we  are  more  likely  to  have  bulging  of  the  intercostal  spaces, 
and  on  inspection  a  visible  alteration  of  the  cardiac  area,  than  in  adults.- 

It  has  been  held  by  certain  authorities  that  the  heart's  apex  is  found  in 
effusions  to  be  tilted  upward  and  inward  toAvards  the  sternal  end  of  the 
fourth  left  interspace, — that  is,  floated  by  the  effusion.  Direct  proof  of  this 
is  wanting,  and  we  believe,  from  Rotch's  investigations  on  this  subject, 


756  TEDIATRICS. 

that  it  is  an  erroneous  view.  It  would  seemingly  be  impossible  for  the 
heart  to  be  floated  unless  the  specific  gravity  of  the  fluid  was  greater 
than  1050,  as  Rotch  has  shown  by  experiment.  It  is  highly  improbable 
that  the  specific  gravity  would  be  greater  than  1050  in  an  ordinary  peri- 
cardial exudation,  for  the  specific  gravity  of  a  purely  purulent  fluid  is 
only  aljout  1032.  Ludwig  and  Bowditch  have,  moreover,  observed  that 
the  impulse  of  the  heart  as  seen  normally  in  the  fifth  left  interspace  need 
not  be  caused  by  the  heart's  apex,  but  may  be  caused  by  a  portion  of  the 
heart  above  the  apex  striking  against  the  thoracic  wall.  We  should  also 
consider  .that  the  impulse  of  the  heart  in  children  is  often  chiefly  in  the 
fourth  interspace.  It  seems  plausible  to  account  for  this  pulsation  by  the 
tumultuous  action  of  that  portion  of  the  right  ventricle  which,  as  shown 
by  Rotch,  is  not  covered  by  the  moderate  amount  of  fluid  in  the  fourth 
left  interspace  when  an  exudation  is  present. 

In  the  third  case  on  page  761  it  is  recorded  that  the  impulse  was  found 
throughout  the  Avhole  cardiac  area,  but  that  it  was  still  pronounced  in  the 
fifth  left  interspace.  If  in  this  case  there  had  been  a  larger  exudation,  the 
apex  and  the  lower  segment  of  the  right  ventricle  being  surrounded  by  a 
mass  of  fluid,  the  impulse  would  have  been  lost  in  the  fifth  interspace, 
while  in  the  fourth  interspace,  in  which  the  ventricle  may  be  covered  by 
only  a  thin  layer  of  overlying  fluid,  the  impulse  would  have  continued 
to  be  both  seen  and  felt,  thus  simulating  an  apex-beat.  We  believe  this  is 
the  explanation  of  what  has  been  called  misplaced  apex-beats  and  floating 
of  the  heart  in  pericardial  eff'usions. 

Palpation. — ^When  the  amount  of  fluid  is  considerable  the  palpable 
impulse  is  much  diminished,  and  its  intensity  corresponds  to  the  place  in 
which  the  visible  impulse  is  most  distinct. 

Auscultation. — The  friction-sound  is  often  absent,  but  if  present  in  the 
beginning  disappears  as  the  fluid  increases,  and  may  reappear  when  ab- 
sorption takes  place.  The  heart-sounds  are  diminished  in  intensity,  but 
may  be  heard  most  distinctly  in  the  fourth  interspace  at  the  point  of  the 
visible  impulse.  On  account  of  the  small  size  of  the  child's  thorax,  the 
heart  and  pericardium  are  much  nearer  to  the  anterior  surface  of  the 
thoracic  cavity  than  in  adults.  This  occurs  both  normally  and  in  diseased 
conditions,  especially  when  there  is  flattening,  and*  thus  levelling,  of  the 
chest.  Under  these  latter  conditions  the  heart  and  pericardium  are 
brought  in  such  close  contact  with  the  thoracic  wall  that  on  palpation  the 
heart's  impulse  can  be  felt,  and  on  auscultation  the  heart-sounds  can  be 
heard  in  a  much  more  advanced  stage  of  a  pericardial  effusion  than  would 
be  possible  in  the  adult  with  a  proportionately  large  amount  of  fluid. 

According  to  Ewarts,  a  pericardial  exudation  may  give  rise  to  a  patch 
of  tubular  breathing  about  two  inches  below  and  slightly  to  the  left  of  the 
left  scapula,  but  the  same  sign  may  occur  in  pleuritic  exudation. 

Percussion. — Percussion  is  the  most  important  physical  sign,  when  the 
initial  friction-sound  has  escaped  detection,  both  for  determining  whether 


DISEASES    OF   THE   PERICARDIUM.  757 

an  exudation  is  present  and  as  a  guide  to  the  prognosis  and  treatment. 
In  exudations  of  exactly  the  same  amount  the  area  of  duhiess  may  differ, 
owing  to  the  difference  in  the  elasticity  of  the  lungs  and  to  the  presence 
or  absence  of  adhesions.  The  greater  the  elasticity  of  the  lungs  and  the 
fewer  the  adhesions  the  more  regular  will  be  the  outlme  of  superficial 
dulness.  This  superficial  dulness  is  determined  by  the  retraction  of  the 
borders  of  the  lungs,  which  withdraw  from  the  chest  walls  as  the  fluid 
gradually  distends  the  pericardium.  The  deep'  dulness  is  due  to  the  dis- 
tended pericardium,  and  this  to  a  greater  or  less  degree  compresses  the 
lungs,  which  may  be  held  in  position  by  adhesions.  The  infant,  being 
less  likely  to  have  had  previous  lesions  of  the  lung  and  pericardium,  gives 
us  the  best  opportunity  for  studying  the  outlmes  of  a  pericardial  effusion, 
and  the  area  of  superficial  dulness  is  the  most  valuable  physical  sign  of 
effusion  in  infants  and  in  young  cliildren. 

The  experiments  (Keattng's  Cyclopsedia  of  Diseases  of  Children)  on 
which  Rotch  based  his  conclusions  regarding  the  area  of  dulness  in  peri- 
cardial effusions  were  made  on  sixteen  infants,  in"  none  of  whom  did  ad- 
hesions exist.  In  all  of  these  presumably  typical  cases  absolute  dulness 
was  found  to  the  right  of  the  sternum.  An  instance  of  how  the  area  of 
dulness  varies  in  cases  complicated  ^^ith  adhesions  was  given  by  a  case 
in  which,  although  the  pericardium  was  much  distended  with  fluid,  it 
failed  to  show  dulness  to  the  right  of  the  sternum,  and  the  autopsy  re- 
vealed adhesions  binding  the  lung  tightly  to  the  right  edge  of  the  sternum. 
The  effusion  was  behind  the  lung,  which  permitted  resonance  to  be  ob- 
tamed  over  an  area  where,  in  an  uncomplicated  case  with  the  same 
amount  of  effusion,  there  would  have  been  dulness. 

In  addition  to  the  difficulties  of  making  a  differential  diagnosis  arising 
from  interference  "with  the  contractility  of  the  lungs,  such  complications  as 
pneumonia  of  the  right  lung,  especially  its  middle  lobe,  pleuritic  effusion 
on  the  right  side,  an  enlarged  liver,  and  an  enlarged  heart  must  be  con- 
sidered. When  this  pnemnonia,  or  pleurisy,  or  hepatic  enlargement  is 
present,  an  effusion  into  the  pericardium  cannot  be  diagnosticated  by 
means  of  percussion,  but  the  associated  disease  can  usually  be  readily 
determined  by  its  especial  symptoms.  The  differential  diagnosis,  on  the 
contrary,  from  an  enlarged  heart,  especially  a  dilated  heart  in  which 
the  murmurs  may  be  absent,  can  often  be  made  only  by  means  of  per- 
cussion. 

The  superficial  dulness  of  the  heart  is  determined  not  by  the  shape  of 
the  heart  itself,  but  by  the  marginal  lines  of  the  lungs,  varying  according 
to  their  expansion  or  retraction.  Moreover,  the  pericardium  itself, 
whether  distended  with  fluid  or  not,  does  not  by  its  own  shape,  as  has 
been  delmeated  so  often  in  the  plates  illustrating  pericardial  effusions,  aid 
us  materially  in  determining  the  shape  of  the  area  of  superficial  dulness 
in  a  pericardial  effusion.  This  area  is  marked  by  the  retracting  or  rather 
displaced  borders  of  the  lungs. 


758  PEDIATRICS. 

When  from  70  to  88  c.c.  (2^  to  2-|-  ounces)  of  fluid  are  introduced 
into  the  pericardium  of  an  adult,  there  is  a  slight  increase  in  the  vertical 
as  well  as  in  the  transverse  area  of  dulness.  The  curved  line  which 
bounds  the  area  of  dulness  starts  at  the  sixth  rib,  to  the  right  of  the 
sternum,  passes  upward  to  the  junction  of  the  fourth  cartilage  with  the 
sternum,  impinges  on  the  lower  part  of  the  third  left  interspace,  and  then 
descends  just  outside  of  the  mammillary  line  to  the  sixth  rib,  to  pass  in- 
ward until  it  meets  the  dulness  of  the  left  lobe  of  the  liver.  This  line 
forms  an  irregular  semicircle,  with  a  shorter  radius  to  the  right  of  the 
sternum  and  a  longer  one  to  the  left. 

A  small  section  of  the  dull  area,  corresponding  to  the  junction  of  the 
fourth  and  fifth  ribs  with  the  left  side  of  the  sternum,  is  formed  by  the 
heart  itself,  which  is  free  from  effusion  at  this  point,  while  the  rest  of  the 
dulness  is  produced  by  the  effusion.  The  layer  of  fluid  is  very  thin  all 
over  the  upper  portion  of  the  effusion  in  the  region  of  the  fourth  rib  and 
fourth  interspace,  while  the  mass  of  the  effusion  is  in  the  lower  part  of 
the  sac  on  each  side  of  the  sternum  in  the  fifth  interspaces,  the  larger 
part  of  the  mass  being  on  the  left  side. 

The  same  conclusions  as  to  the  area  of  dulness  were  obtained  with  a 
proportionately  small  amount  of  fluid  in  an  infant  about  two  weeks  old ; 
and  of  sixteen  injections  of  fluid  into  the  pericardial  sac  of  infants  of 
various  ages  the  areas  of  dulness  were  identical  in  all,  and  in  all  the 
lungs  were  normal  and  there  were  no  pulmonary  or  other  adhesions. 

When  the  amount  of  fluid  in  the  pericardial  sac  is  large,  the  transverse 
area  of  dulness  produced  by  the  much  distended  pericardium  is  increased 
so  that  it  extends  farther  to  the  right  of  the  sternum  in  the  fourth  and 
fifth  interspaces,  and  then,  rising  to  the  third  interspace,  it  occupies 
a  small  area  on  either  side  of  the  sternum  under  the  third;  second, 
and  first  ribs  and  the  second  and  first  interspaces,  the  upper  lobes  of 
the  lungs  having  retracted  from  beneath  the  sternum.  As  the  effusion 
increases  the  lungs  retract  still  more,  and  the  upper  curved  lines  of  the 
_effusion  on  either  side  of  the  sternum  present  areas  with  still  greater 
diameters. 

According  to  Ewarts,  a  pericardial  exudation  may  at  times  give  rise 
to  a  patch  of  dulness  in  the  back  represented  by  a  sharply  defined  square 
area  bounded  by  the  ninth  or  tenth  rib  above  and  the  twelfth  rib  below, 
on  the  right  by  the  spine,  and  on  the  left  by  a  vertical  line  from  the  angle 
of  the  scapula.  Over  this  area  the  respiratory  sounds  are  absent  and  the 
voice-sounds  feeble.  We  have  observed  these  same  signs  in  a  number  of 
cases  in  which  the  dulness  disappeared  as  the  pericardial  effusion  was 
absorbed. 

Ewarts  has  also  given  as  a  point  in  the  differential  diagnosis  between 
pericardial  exudation  and  cardiac  dilatation,  that  in  a  dilated  heart  the 
curve  of  the  right  border  of  dulness  is  directed  downward  and  inward 
towards  the  ensiform  cartilage,  while  in  a  pericardial  exudation  the  curve 


DISEASES   OF   THE   PERICARDIUM.  759 

is  directed  either  downward  or  downward  and  outward.  Tliis  distinction 
is  more  easily  made  in  moderate  than  in  very  large  exudations,  as  shown 
in  Fig.  158,  page  760. 

Diagnosis. — From  what  has  been  said  regarding  the  latency  of  the 
general  symptoms  of  pericarditis  in  childhood  and  the  difficulty  of  inter- 
preting the  local  symptoms,  it  will  be  readily  understood  how  important 
it  is  to  recognize  any  especial  symptoms  which  may  characterize  the  dis- 
ease. Instances  have  been  reported  in  which  a  distended  jDericardium 
Avas  mistaken  by  experienced  diagnosticians  for  an  exudation  into  the 
left  pleura.  The  diagnosis  as  to  the  character  of  the  effusion,  whether 
serous  or  purulent,  can  only  be  made  by  aspiration.  In  infants  the  fluid 
is  almost  uniformly  pus ;  this  is  also  the  case  in  the  majority  of  older 
children,  except  in  rheumatic  infections.  The  condition  which  most 
closely  simulates  a  pericardial  exudation,  both  in  its  general  symptoms 
and  in  its  physical  signs,  is  a  dilated  heart. 

The  most  distinctive  of  all  the  physical  signs  of  pericarditis  is  the 
friction-sound,  when  it  is  present,  but  it  must  be  carefully  differentiated 
from  the  sound  produced  by  a  dry  pleurisy  m  the  cardiac  area.  When, 
however,  an  exudation  has  taken  place,  the  friction-sound  may  not  be 
heard.  This  absence  of  a  friction-sound  is  especially  frequent  in  young 
children.  The  heart's  impulse  may  be  clearly  perceptible,  even  when  a 
considerable  exudation  is  present,  owing  to  the  thin  layer  of  fluid  which 
covers  the  heart  in  the  area  between  the  left  nipple  and  the  sternum. 
We  are  therefore  forced  by  the  similarity  which  at  times  exists  between 
the  general  symptoms,  in  the  inspection,  palpation,  and  auscultation  of  a 
dilated  heart  and  of  a  pericardial  exudation,  to  depend  upon  percussion  in 
making  a  differential  diagnosis. 

According  to  careful  observations  which  have  been  made  by  com- 
petent observers  on  the  area  of  dulness  which  can  be  produced  by  an 
enlargement  either  of  the  ventricles  or  auricles  of  the  heart,  whether  by 
hypertrophy  or  by  dilatation,  the  relative  dulness  may  extend  to  the  right 
of  the  sternum  from  the  second  to  the  sixth  rib,  and  in  adults  possibly  to 
the  distance  of  3  or  4  cm.  (1^  or  IJ  inches)  on  a  level  with  the  fourth 
rib,  but  it  is  rare  to  find  this  dulness  invading  the  fifth  right  interspace 
more  than  2  or  3  cm.  (|  or  1^  inches).  It  is  still  more  rare  for  the  abso- 
lute dulness  to  be  found  in  the  fifth  interspace  at  all,  and  even  in  the 
fourth  interspace  for  more  than  1.5  or  2  cm.  (J  or  |  inch). 

We  may  conclude,  therefore,  that  the  dulness  wdiich  occurs  in  a  peri- 
cardial effusion  may  correspond  to  that  of  an  enlarged  heart,  but  that 
the  dulness  of  the  effusion  is  also  found  in  an  additional  area  correspond- 
ing to  a  part  of  the  fifth  rib  and  fifth  interspace.  Absolute  dulness, 
therefore,  in  the  fifth  right  interspace  3  or  4  cm.  (1^-  or  1|  mches)  ft-om 
the  right  sternal  line  in  cases  of  pericarditis  uncomplicated  by  pleural  or 
pericardial  adhesions  is  a  sign  of  much  value  in  the  differential  diagnosis 
from  an  enlarged  heart.    Rotch  has  found  in  his  experiments  on  the  aduft 


760 


PEDIATRICS. 


pericardium  that  the  superficial  dulness  could  be  detected  in  the  fifth  right 
interspace  when  from  70  to  80  c.c.  of  fluid  had  entered  the  pericardium. 
In  order  to  illustrate  the  difference  between  the  area  of  dulness  pro- 
duced by  an  enlarged  heart  and  that  produced  by  a  pericardial  effusion,  we 
have  indicated  in  Fig.  158,  a  boy,  eleven  and  a  half  years  old,  the  boun- 


PiG.  158. 


Areas  of  absolute  dulness  iu  enlarged  heart,  and  in  distended  pericardium,    b,  tilth  right  interspace ; 

H,  heart. 

Haries  of  the  area  of  absolute  dulness  in  an  enlarged  heart,  in  a  small 
pericardial  effusion,  and  in  a  large  pericardial  effusion. 

The  top  of  the  sternum,  the  boundaries  of  the  enlarged  heart,  the 
ensiform  cartilage,  and  the  lower  border  of  the  ribs  are  marked  by  plain 
black  lines,  the  boundaries  of  the  small  effusion  by  a  broken  line,  and 
the  area  of  the  large  effusion  by  a  larger  broken  line.  The  figure  5 
marks  the  fifth  right  interspace  ;  the  letter  H  marks  that  portion  of  the 
heart  which  has  been  left  uncovered  by  the  small  effusion.  The  small 
black  circle  represents  the  normal  position  of  the  apex  of  the  heart,  the 
larger  circle  the  apex  of  the  enlarged  heart.  It  will  be  noticed  how  the 
enlarged  heart  extends  beyond  the  right  edge  of  the  sternum  at  about  the 
fourth  rib  and  fourth  interspace,  and  then  returns  beneath  the  lower  part 
of  the  sternum  within  or  a  very  little  outside  of  the  right  sternal  linec 


DISEASES    OF   THE   PERICARDIUM. 


761 


The  outline  of  the  small  effusion,  as  well  as  that  of  the  large  effusion, 
extends  to  the  right  of  the  sternum  as  low  as  the  sixth  rib. 

The  following  cases,  taken  from  a  number  which  have  come  under 
our  care,  illustrate  the  difficulty  of  making  a  differential  diagnosis  between 
cardiac  and  pericardial  disease  when,  as  at  times  happens,  we  fail  to  find 
a  friction-sound  or  murmurs  : 

TABLE  67. 

Differential  Diagnosis  between  a  Dilated  Heart  and  a  Pericardial  Effusion. 


Case  I. 
Endocarditis  :  Dilated  Heart. 


Girl,  eleven  years. 

Attack  followed  acute  artic- 
ular rheumatism. 

Orthopnoea ;  precordial  pain. 

Heart's  impulse  feeble,  but 
perceptible  a  little  to  left 
and  below  left  nipple,  fifth 
interspace. 

Vertical  absolute  dulness  not 
increased. 

Absolute  dulness  under  the 
sternum  and  to  left  of 
sternum ;  identical  with 
Cases  II.  and  III. 

Absolute  dulness  did  not  ex- 
tend to  ri^ht  of  sternum. 


Systolic  murmur  at  apex. 


Kecovery. 


Case  II. 
Pericarditis ;  Effusion. 


Boy,  six  years. 

Attack  followed  acute  artic- 
ular rheumatism. 

Orthopnoea;  precordial  pain. 

Heart's  impulse  feeble,  but 
perceptible  a  little  to  left 
and  below  left  nipple,  fifth 
interspace. 


Vertical  absolute  dulness  not 
increased. 

Absolute  dulness  under  the 
sternum  and  to  left  of 
sternum ;  identical  with 
Cases  I.  and  III. 

Absolute  dulness  in  fifth 
right  interspace  two  or 
three  centimetres  from 
edge  of  sternum. 


Pericardial 
base. 


Eecovery. 


friction-rub    at 


Case  III. 

Endocarditis  ;  Enlarged  Heart ; 

Pericardial  Effusion. 


Girl,  eight  years.     August  3. 

Attack  followed  acute  articular 
rheumatism. 

Orthopnoea ;  precordial  pain. 

Heart's  impulse  feeble,  but  per- 
ceptible all  over  cardiac  area, 
with  apex-beat  a  little  below 
and  to  left  of  left  nipple,  fifth 
interspace. 

Vertical  absolute  dulness  not 
increased. 

Absolute  dulness  under  the  ster- 
num and  to  left  of  sternum  ; 
identical  with  Cases  I.  and 
II. 

Absolute  dulness  in  fifth  right 
interspace  three  or  four  cen- 
timetres from  edge  of  ster- 
num. 

Soft  systolic  murmur  at  apex, 
transmitted  to  axilla.  Peri- 
cardial friction-rub  at  base. 

August  6  :  Less  dulness  in  fifth 
right  interspace ;  apex  mur- 
mur much  louder  aiid  harsh. 

August  11  :  Dulness  only  to 
right  edge  of  sternum. 

August  18 :  Dulness  only  to 
middle  of  sternum  ;  friction- 
rub  ceased. 

December  1 :  Physical  examina- 
tion the  same  as  on  August 
18,  showing  enlarged  heart 
and  mitral  systolic  murmur. 


762 


PEDIATRICS. 


The  symptomatology,  both  general  and  local,  of  these  cases  was,  with 
the  exception  of  the  friction-sounds,  murmurs,  and  percussion,  identical ; 
when  fkiid  was  present  dulness  was  found  in  the  fifth  right  interspace, 
and  when  it  was  absent  dulness  was  not  found. 

Prognosis. — The  prognosis  of  acute  pericarditis  depends  largely  upon 
its  cause.  In  early  infancy  it  is  a  very  serious  condition,  and  generally 
ends  fatally.  In  later  childhood  its  course  and  results  are  much  the  same 
as  in  adults,  and  the  disease  has  a  tendency  to  recovery,  especially  if  the 
exudation  is  sero-fibrinous  and  of  rheumatic  origin.  The  purulent,  septic, 
and  tubercular  forms  are  of  grave  import  in  all  cases. 

Treatment. — The  treatment  of  pericarditis  in  infancy  and  in  early 
childhood  does  not  differ  materially  from  that  in  later  life,  and  depends 
upon  the  various  causes  referred  to  in  the  etiology  of  the  disease.  The 
tendency  to  heari-failure,  however,  which  is  so  pronounced  in  the  child, 
should  be  guarded  against.  Early  in  the  disease  absolute  physical  and 
mental  rest  should  be  enforced.  In  the  acute  stage,  before  an  effusion  of 
any  extent  has  formed,  cold  can  be  applied  to  the  cardiac  region  by  means 
of  coils  of  tubing  containing  ice-water  or  by  an  ice-bag.  An  important  part 
of  the  treatment  is  the  judicious  administration  of  digitalis  to  aid  the  heart 
in  the  crippled  condition  in  which  it  is  usually  left  after  the  early  days  of 
the  disease.  Stmiulants  should  be  freely  used  when  there  is  any  indication 
of  failing  compensation. 

The  most  important  part  of  the  treatment  when  an  effusion  of  any 
extent  has  occurred  is  paracentesis  of  the  pericardium,  which  should  un- 
hesitatingly be  performed,  no  matter  w^hat  the  cause  of  the  disease  may  be, 
when  life  is  in  danger  from  undue  distention  of  the  pericardial  sac.  A 
small  aspirating  trochar  should  be  used.  Opinions  differ  widely  as  to  the 
best  point  of  puncture.  Inasmuch  as  the  heart,  when  an  effusion  is  pres- 
ent, remains  in  its  usual  position,  and  does  not,  even  when  much  enlarged, 
impinge  on  the  fifth  right  interspace,  and  as  the  effusion,  even  when  in 
so  small  an  amount  as  100  c.c,  is  found  at  that  point,  we  consider  it  more 
rational  to  choose  the  fifth  right  interspace,  4  cm.  (1|  inches)  outside  the 
right  border  of  the  sternum,  as  the  point  for  tapping,  thus  avoiding  all 
danger  of  injuring  the  heart.  At  this  point  the  right  internal  mammary 
artery  will  not  be  injured.  We  have  tapped  the  pericardium  in  the  fifth  right 
interspace  a  number  of  times  on  the  cadaver,  and  have  removed  the  fluid 
as  easily  as  in  the  fifth  left  interspace.  The  pericardium  has  been  tapped 
during  life  in  the  fifth  right  interspace  by  Ebstein,  of  Gottingen,  Wilson, 
of  Nashville,  Lovejoy,  of  Lynn,  and  a  number  of  others.  Another  place 
to  aspirate,  recommended  by  Osier,  is  the  left  fourth  interspace,  either 
close  to  the  sternal  margin  or  2.5  cm.  (one  inch)  from  it,  in  order  to 
avoid  w^ouncling  the  internal  mammary  artery.  The  left  fifth  interspace, 
3.75  cm.  (1|  inches)  from  the  sternal  border,  may  also  be  taken  for  the 
point  of  puncture,  and  if  the  aspirated  fluid  is  found  to  be  purulent,  the 
case  should  be  treated  surgically  by  free  incision. 


DISEASES   OF   THE   PERICARDIUM.  763 

As  an  illustration  of  how  important  it  is  to  tap  the  pericardium  when 
it  is  much  distended  witli  fluid  and  when  symptoms  of  failing  heart  have 
arisen,  the  following  case  may  be  cited  : 

A  boy,  six  years  old,  entered  the  hospital  with  the  history  of  having  had  cedema 
of  the  face,  hands,  feet,  and  ankles  for  four  weeks.  There  was  no  history  of  rheu- 
matic fever,  and  the  case  was  apparently  one  of  acute  primary  endocarditis  with  mitral 
insufficiency.  The  cardiac  area  of  dulness  was  increased,  and  extended  from  the 
middle  of  the  sternum  to  1.5  cm.  (^  inch)  beyond  the  left  mammillary  line,  where 
the  impulse  of  the  heart  could  be  felt.  The  child  was  kept  quiet  in  bed,  and  after  a 
few  days  the  cedema  lessened  and  he  was  very  comfortable.  While  still  under  treat- 
ment, two  weeks  later,  the  temperature,  which  had  been  normal,  rose  to  39.1°  C. 
(102.5°  F.),  the  pulse  was  rapid  and  somewhat  irregular,  and  the  respirations  were 
increased.  A  few  days  later  a  pericardial  friction-sound  was  heard  over  the  upper 
part  of  the  sternum,  and  the  temperature  fell  to  37.7°  C=  (100°  F.).  There  was  no 
change  in  the  area  of  cardiac  dulness,  and  no  evidence  of  a  pericardial  effusion. 

On  the  following  day  the  cardiac  sounds  were  found  to  be  rather  muffled  and 
the  child  did  not  seem  so  well,  and  was  unable  to  lie  on  his  left  side.  Two  days  later 
the  area  of  precordial  dulness  extended  farther  to  the  right,  and  a  little  beyond  the 
right  sternal  line  in  the  fifth  right  interspace.  The  attendants  were  directed  to  watch 
the  child  closely,  and  warning  was  given  that  the  necessity  for  paracentesis  of  the 
pericardium  might  at  any  time  arise.  Early  the  following  morning  the  child  began  to 
have  marked  dyspnoea  and  became  very  cyanotic.  The  house-officer  found  that  the 
precordial  dulness  had  extended  2.7  cm,  (1  inch)  beyond  the  right  edge  of  the  sternum 
in  the  fifth  interspace,  and  he  therefore  got  the  instruments  ready  for  performing  para- 
centesis. Suddenly  the  child's  pulse  became  very  weak  and  intermittent,  the  cyanosis 
increased  very  much,  the  dyspnoea  became  very  marked,  and,  although  stimulants  were 
quickly  given,  the  child  suddenly  gasped  airid  fell  back  on  its  pillow  dead.  This  oc- 
curred within  three-quarters  of  an  hour  from  the  time  when  the  first  serious  symptoms 
arose.  The  house-officer  immediately  introduced  the  aspirating  needle  in  the  fifth 
right  interspace  and  withdrew  some  fluid  from  the  pericardium.  The  child,  however, 
did  not  revive. 

The  following  case  illustrates  a  pericarditis  sicca  with  adhesions : 

The  child  was  six  and  one-half  years  old.  She  had  never  had  rheumatic  fever,  but 
had  had  an  attack  of  measles  when  she  was  two  years  old,  pertussis  when  she  was 
two  and  one-half  years  old,  and  parotitis  when  she  was  three  and  one-half  years  old. 
Four  months  previous  to  her  second  entrance  to  the  hospital  she  had  an  attack  of 
chorea,  of  so  mild  a  grade,  however,  that  she  was  able  to  go  to  school  until  she  entered 
the  hospital.  At  that  time,  although  she  did  not  show  any  especial  cardiac  symptoms, 
an  examination  of  the  heart  showed  a  latent  and  insidious  endocarditis,  represented 
by  an  increase  of  the  superficial  area  of  cardiac  dulness  to  the  left  of  the  mammillary 
line,  but  not  extending  under  the  sternum,  with  a  systolic  murmur  transmitted  to  the 
axilla,  but  not  heard  in  the  back.  Compensation  soon  became  complete,  and  she  re- 
covered from  the  chorea. 

Two  days  before  her  second  entrance  to  the  hospital  she  was  attacked  with  dyspnoea, 
rapid  respirations,  and  cardiac  pain. 

On  examination  the  child  seemed  very  sick,  and  showed  a  considerable  increase 
to  the  left  in  the  area  of  cardiac  dulness,  and  at  the  junction  of  the  third  rib  with  the 
sternum  a  marked  precordial  friction-sound,  but  with  no  enlargement  to  the  right. 

The  precordial  pain,  discomfort,  and  heightened  temperature  lasted  for  a  few  days, 
and  were  in  the  beginning  accompanied  by  orthopnoea  and  by  an  increase  in  the  loud- 


764  PEDIATRICS. 

ness  of  the  friction-sound.  There  was  at  no  time,  however,  any  evidence  of  an  effusion 
in  the  pericardium,  and  one  week  afterwards  the  friction-sound  became  less  distinct, 
disappearing'three  days  later.  The  child,  however,  grew  much  weaker,  and,  although 
she  was  treated  by  complete  rest  in  bed  and  with  digitalis,  strophanthus,  and  stimu- 
lants, the  precordial  pain  returned,  and  she  gradually  failed  and  died.  The  pulse 
varied  from  130  to  150,  and  the  respirations  from  50  to  80.  The  temperature  was  only 
moderately  elevated  throughout  the  attack,  ranging  between  37.7°  to  38.8°  C.  (100°  to 
102°  F.)  most  of  the  time. 

The  autopsy  showed  the  pericardial  sac  to  be  obliterated  everywhere  by  firm  fibrin- 
ous adhesions.  The  heart  was  enlarged.  Along  the  edges  of  the  mitral  valve  were 
numerous  small  grayish-white  vegetations.  These  were  also  present  on  the  aortic 
valves  and  on  the  portion  surrounding  the  tricuspid  valve.  The  lungs  were  denser 
than  normal,  and  were  deeply  injected  and  cedematous.  The  pleura  on  the  inner 
surface  of  the  right  lower  lobe  was  adherent  to  the  pericardium  by  fibrinous  adhesions. 
The  surface  of  the  liver  was  covered  with  a  thin  layer  of  fibrin.  The  liver  and  kidneys 
were  a  little  denser  than  normal,  but  were  not  noticeably  congested. 

The  anatomical  diagnosis  was  chronic  adhesive  pericarditis,  acute  vegetative  endo- 
carditis, acute  fibrinous  pleurisy,  acute  fibrinous  perihepatitis,  and  hypertrophy  and 
dilatation  of  the  heart. 

The  next  case  was  one  of  marked  pericardial  effusion,  which  was 
absorbed : 

A  little  girl,  eight  years  old,  during  the  first  two  years  of  her  life  had  scarlet  fever, 
varicella,  and  pertussis.  When  she  was  two  years  old  she  had  an  attack  of  measles, 
and  when  she  was  seven  years  old  an  attack  of  chorea.  During  the  last  year  she  was 
fairly  well  until  two  weeks  before  entrance,  when  it  was  noticed  that  her  feet  began  to 
swell,  she  complained  of  pain  in  her  limbs,  and  occasionally  of  headache,  she  lost  in 
weight,  and  had  had  orthopncea  with  frequent  paroxysms  of  dyspnoea.  She  also  at 
times  complained  of  pain  in  her  left  chest.  Her  extremities  were  apt  to  be  cold.  She 
had  a  short,  dry  cough.  A  physical  examination  showed  the  impulse  of  the  heart  to  be 
feeble,  but  it  could  be  felt  all  over  the  cardiac  area.  There  was  an  area  of  precordial 
dulness  extending  to  the  right  of  the  sternum  almost  to  the  right  mammillary  line,  as  low 
as  and  involving  the  fifth  interspace  and  as  high  as  the  third  interspace  and  to  the  left 
a  little  beyond  the  left  mammillary  line  to  the  sixth  rib.  There  was  a  systolic  murmur 
at  the  apex,  which  was  transmitted  to  the  axilla.  The  pulmonic  second  sound  was 
accentuated.  There  was  a  precordial  friction-sound  heard  at  the  upper  part  of  the 
sternum.  The  history  of  the  case  and  the  area  of  precordial  dulness  showed  that  it 
was  a  case  of  pericarditis  with  efl'usion.  There  may  also  have  been  some  endocarditis, 
evidence  of  which  is  given  by  the  mitral  systolic  murmur.  The  child  was  treated  by 
rest  in  bed  and  by  digitalis. 

Two  weeks  later  the  friction-sound  disappeared,  and  the  precordial  dulness  grew 
less,  so  that  it  extended  only  to  the  middle  of  the  sternum.  In  the  next  two  weeks 
the  dulness  beneath  the  sternum  disappeared,  and  the  mitral  murmur  lessened,  but 
could  still  be  heard  2  cm.  (f  inch)  outside  of  the  mammillary  line. 

CHRONIC  ADHESIVE  PERICARDITIS. 
Chronic  adhesive  pericarditis  may  occur  in  infancy  and  childhood.  It 
is  the  result  of  acute  inflammatory  processes,  in  the  course  of  which  the 
parietal  and  visceral  layers  of  the  pericardium  become  adherent  by  the 
fibrinous  exudation,  Avhich  later  becomes  oi^nized  fibrous  tissue.  These 
adhesions  may  be  partia"  or  complete,  involving  the  obliteration  of  the  en- 


DISEASES   OF   THE   PERICARDIUM.  765 

tire  pericardial  canity.     Well-marked  adhesions  of  the  pericardial  surfaces 
have  been  obser^-ed  in  an  infant  \vho  died  thirty-six  hours  after  birth. 

If  the  adhesions  are  limited  to  the  visceral  and  parietal  layers  of  the 
pericardium,  there  may  be  no  resulting  cardiac  disturbance,  and  in  many 
cases  there  is  neither  hypertrophy  nor  dilatation. 

If,  hov^'ever,  an  obliterated  pericardium  is  associated  with  inflamma- 
tory' adhesions  between  the  outer  layers  of  the  pericardium  and  the 
pleura  and  chest  walls,  the  hypertrophy  of  the  heart  may  become  extreme 
and  eventually  result  in  dilatation  or  sudden  death. 

The  white,  opaque  thickenings  of  the  inner  pericardial  surface  so 
frequently  found  in  adults  are  rare  in  children,  but  have  been  found  at 
ail  ages,  and  when  there  is  a  deformity  of  the  chest,  as  in  certain  cases 
of  rhachitis,  they  have  been  especially  noticed.  The  younger  the  subject 
the  less  likely  are  there  to  be  adhesions  between  the  pericardium  and  the 
pleura,  an  important  fact,  to  be  taken  into  consideration  when  making  a 
diagnosis  of  pericardial  effusion  in  mfancy.  The  frequency  of  pericar- 
dial adhesions  is  shown  in  Lee's  series  of  one  hundred  and  fifty  autopsies 
in  cardiac  disease  of  rheumatic  origin,  in  which  one  hundred  and  thirteen 
cases  had  pericardial  adhesions,  and  of  these,  seventy-seven  had  complete 
adhesion.  An  important  result  of  pericarditis  is  the  injury  done  to  the 
myocardium  through  the  intimate  connection  between  the  "visceral  layer 
of  the  pericardium  and  the  heart-muscle.  Lee  in  thirty-four  of  his  cases 
found  changes  in  the  myocardium  after  pericarditis. 

In  the  fibrinous  pericarditis  of  rheumatic  origin  the  process  is  likely 
to  be  of  a  very  mild  grade,  with  but  a  slight  increase  in  the  connective 
tissue  between  the  membranes,  and  consequently  with  but  little  thicken- 
ing. The  most  extreme  cases  of  thickening  of  the  pericardial  membrane 
is  met  with  in  the  chronic  tubercular  form.  In  these  cases  there  is  always 
a  primary  tuberculosis  of  the  mediastinal  or  bronchial  lymph-nodes.  The 
tubercular  process  invades  the  pericardium  by  extension  from  these  foci. 
This  is  not  an  uncommon  process  in  children.  Of  sixty-five  cases  col- 
lected by  Brackman,  nineteen  occurred  in  children. 

After  the  absor^Dtion  of  an  extensive  purulent  or  sero-purulent  exuda- 
tion, the  resulting  thickening  of  the  pericardium  may  be  increased  by  the 
deposition  of  lime-salts  within  the  membranes  leading  to  calcification. 
Such  areas  of  calcification  are  most  frequently  found  over  the  auricles  or 
at  the  base  of  the  heart.  According  to  Osier,  the  heart  may  be  com- 
pletely invested  by  a  calcareous  membrane  which  in  places  may  be  from 
1  to  1.5  centimetres  {-^  to  -^  inch)  in  thickness. 

SyiMptoms. — The  symptoms  of  adhesive  pericarditis  are  not  distinctive. 
They  are  generally  dependent  upon  the  condition  of  hypertrophy  and 
dilatation  which  is  present  and  upon  the  degree  of  compensation. 

At  times  the  symptoms  are  suggestive  of  cirrhosis  of  the  liver, — that  is, 
enlargement  of  the  liver  and  ascites.  When  these  occur  without  obvious 
cause  in  a  young  person,  adhesive  pericarditis  should  be  suspected. 


766  PEDIATRICS. 

When  severe  cai'diac  symptoms  are  present  in  young  children  and  no 
valvular  murmurs  are  heard,  we  should  think  of  degeneration  of  the 
heart-muscle  itself  or  of  pericardial  adhesions.  When,  again,  the  super- 
ficial area  of  dulness  remains  unchanged  and  there  are  well-marked  sys- 
tolic retractions,  the  presence  of  pericardial  adhesions  is  highly  probahle. 

Diagnosis. — The  chief  diagnostic  points  of  adherent  pericardium  asso- 
ciated with  clu'onic  mediastinitis,  arc  bulging  of  the  chest,  systolic  retrac- 
tion at  the  cardiac  apex,  or  in  Traube's  space,  and  systolic  retraction  in 
the  line  of  the  attachment  of  the  diaphragm  (Broadbcnfs  sign).  Associ- 
ated with  this  retraction  may  often  be  seen  a  diastolic  collapse  of  the 
cervical  veins,  the  so-called  Friedrich's  sign.  Systolic  retraction,  however, 
may  occur  in  pronounced  hypertrophy  without  adhesions. 

An  extreme  dilatation  of  the  heart  with  an  adherent  pericardium  will 
give  rise  to  signs  which  closely  resemble  pericarditis  with  exudation.  The 
distinction  between  these  two  conditions  can  only  be  made  by  the  very 
closest  observation  of  the  physical  signs  of  pericardial  exudation  as  de- 
scribed on  page  755.  The  majority  of  the  cases  of  adhesive  pericarditis 
are  not  recognized  during  life,  and  are  only  discovered  at  the  autopsy. 

Treatment. — The  treatment  is  symptomatic,  the  endeavor  bemg  made 
to  maintain  the  compensation  of  the  heart.  When  ascites  is  present, 
withdrawal  by  paracentesis  may  aid  in  the  palliative  treatment. 


DIVISION    XII. 

DISEASES   OF  THE   OESOPHAGUS,  STOMACH,  AND 

INTESTINE. 


INTRODUCTION. 


(ESOPHAGUS. — The  diseases  of  the  oesophagus  are  rare  in  infancy 
and  early  childhood.  There  may  be  congenital  malformations,  such  as 
absence  or  obliteration,  narrowing  or  dilatation,  and  fistulous  communica- 
tion with  various  parts,  such  as  the  trachea,  or  that  congenital  condition 
called  "branchial  fistula,"  described  on  page  282.  The  swallowing  of  hot 
or  corrosive  liquids  may  cause  obstruction,  which  is  occasioned  by  a  cica- 
tricial stricture.  Esophageal  stricture  may  also  occur  as  a  result  of  con- 
genital syphilis.  Pressure  outside  of  the  oesophagus  may  cause  obstruction. 
These  strictures,  especially  those  of  cicatricial  origin,  are  accompanied  by 
a  great  deal  of  muscular  spasm,  which  at  times  is  constant,  and  again  re- 
laxes. Thus,  the  child  will  swallow  with  comparative  freedom  at  inter- 
vals, while  at  other  times  the  obstruction  appears  to  be  complete.  In 
addition  to  the  inability  to  swallow,  and  the  consequent  regurgitation  of 
the  food,  the  secretion  of  saliva  and  mucus  is  often  very  profuse,  and 
causes  symptoms  of  distress  and  choking. 

The  diagnosis  and  treatment  of  these  cases  are  effected  chiefly  by 
means  of  bougies ;  but,  as  much  harm  may  come  from  these  instruments, 
and  as  especial  surgical  knowledge  is  required  to  use  them  and  to  decide 
whether  oesophagotomy  should  be  performed,  we  shall  not  dwell  on  this 
class  of  cases. 

An  inflammatory  condition  of  the  oesophagus  is  said  to  occur  in  young 
infants,  and  is  spoken  of  as  cesophagitis.  It  is  rare.  The  symptoms,  as 
described  by  Billard,  are  unwillingness  to  nurse,  crying,  immediate  regur- 
gitation after  beginning  to  suck,  and  often  some  tenderness  about  the  neck 
on  pressure.  The  prognosis  is  bad.  The  treatment  of  the  active  stage 
of  the  more  severe  forms,  such  as  the  corrosive,  is  by  the  administration 
of  emollients  and  ice.     Morphia  may  be  required  for  the  pain. 

It  is  quite  common  for  children  to  swallow  various /om^rri  bodies^  such 
as  buttons  and  pins.  These  bodies  may  either  be  caught  in  the  back  of 
the  throat  or  lodged  in  the  oesophagus,  instead  of  passing  through  to  the 

767 


768 


PEDIATRICS. 


stomach,  A  careful  examination  of  the  throat  with  the  finger  should  first 
be  made,  and  if  the  foreign  body  is  not  detected  in  the  throat  the  oesoph- 
agus should  be  explored  carefully  with  a  bougie,  and  the  foreign  body  is 
then  usually  pushed  through  into  the  stomach,  unless  it  is  thought  wiser 


Fig.  159. 


1- 


\   ^^^^iT'^^V- 


^"^^ 


^ 


,-i 


Congenita]  dilatation  of  oesophagus,  female,  10  weeks  old  {}4  natural  size). 


to  remove  it  with  the  bristle  probang.  As  a  rule,  if  we  are  fairly  sure  that 
the  foreign  body  has  entered  the  oesophagus,  we  should  let  it  alone,  as  it 
almost  invariably  passes  through  the  intestine  without  harm,  and  usually 
within  forty-eight  hours.  Safety  pins  with  the  pin  unhooked  have  fre- 
quently been  swallowed  and  passed  by  the  rectum  without  apparent 
injury.  In  a  case  which  came  under  our  observation  a  round,  flat  whistle, 
2  cm.  (I  inch)  in  diameter,  was  not  passed  for  eight  days.  The  diet  for 
the  following  twenty-four  to  forty-eight  hours,  or  until  the  body  has  been 
passed  through  the  intestine,  should  be  such  as  will  give  sufficient  con- 
sistency to  the  faeces  to  protect  the  intestine  from  injury  while  the  body  is 


DISEASES   OF   THE   (ESOPHAGUS.  769 

being  passed  over  its  surface.  Various  preparations  of  tlie  cereals  are 
useful  for  this  purpose.  Laxatives  and  cathartics,  unless  some  special 
indication  for  them  arises,  should  be  avoided.  Fig.  159  shows  the  oesoph- 
agus and  stomach  of  an  infant  ten  weeks  old,  with  congenital  dilatation 
of  the  oesophagus. 

The  infant  was  healthy  at  birth,  and  its  mother  had  a  plentiful  supply  of  breast- 
milk.  During  the  first  two  or  three  weeks  of  its  life  nothing  abnormal  was  noticed 
about  it,  except  that  it  vomited  occasionally.  When  it  was  four  weeks  old  it  began  to 
regurgitate,  vomited  the  milk  frequently,  and  lost  in  weight.  The  ffecal  discharges 
showed  that  the  milk  which  reached  the  stomach  and  intestine  was  fairly  digested,  but 
the  discharges  were  infrequent  and  small  in  number.  It  was  weaned  Avhen  it  was  nine 
weeks  old,  and  small  amounts  of  milk,  carefully  modified  in  various  ways,  were  given 
to  it.  No  improvement  in  the  symptoms  followed  this  treatment,  and  although  at 
times  a  small  quantity  of  milk  would  be  retained,  yet,  as  a  rule,  after  a  few  minutes  the 
milk  was  regurgitated.  The  infant  had  no  other  symptoms,  but  rapidly  lost  in  weight, 
and  finally  died  of  exhaustion. 

The  post-mortem  examination  was  made  by  Dr.  Whitney,  and  the  only  pathological 
conditions  found  were  in  the  oesophagus.  The  last  two  inches  of  the  oesophagus  were 
dilated  into  a  more  or  less  cylindrical  swelling,  with  marked  thinning  of  the  walls  and 
atrophy  of  the  mucous  coat.  A  dilatation  had  been  formed  in  which  evidence  of  a  small 
area  about  to  perforate  into  the  mediastinum  was  found.  The  entire  stomach,  as  well 
as  its  cardiac  and  pyloric  orifices,  was  markedly  contracted. 


STOMACH  AND  INTESTINES.— The  diseases  of  the  gastro-enteric 
tract  as  they  occur  in  older  children,  resemble  so  closely  those  of  adults 
that  they  do  not  occupy  a  prominent  place  in  the  clinical  medicine  of  chil- 
dren. In  infancy  and  early  childhood,  however,  we  meet  with  such 
marked  differences  from  a  later  period,  that  their  peculiarities  demand  es- 
pecial description,  and  it  is  this  early  period  of  life  which  we  shall  deal 
with.  These  differences  are  still  more  strongly  marked  from  the  fact 
that  children  succumb  much  more  readily  to  the  early  stages  of  gastro- 
enteric disease  than  do  adults,  and  may  die  before  the  later  and  more 
characteristic  lesions  and  symptoms  of  the  disease  have  developed. 

There  is  such  a  diversity  of  terms  used  by  different  authors  and 
teachers  in  speaking  of  diseases  of  the  gastro-enteric  tract  that  it  Avould  be 
well  if  this  diversity  could  be  done  away  Avith  and  some  systematic  nomen- 
clature adopted,  which  of  course  can  be  provisional  and  subject  to  change. 
A  classification  on  an  anatomical  basis  is  manifestly  inadecpate,  on  account 
of  the  great  discrepancy  between  the  symptoms  and  the  post-mortem 
findings.  In  like  manner  a  classification  on  the  basis  of  symptoms  is 
insufficient  and  unsatisfactory.  On  the  other  hand,  bacteriological  investi- 
gations have  advanced  our  knowledge  to  such  an  extent  that  we  can  now 
classify  these  diseases  on  an  etiological  basis. 

Such  an  etiological  classification  is  represented  in  Table  68,  on  page 
770,  and,  as  is  there  shown,  the  subject  can  be  divided  into  three  broad 
classes  : 

49 


770 


PEDIATRICS. 


I.  Developmental.     II.  Non-infectious.     III.  Infectious. 
Intestinal  worms  can  be  spoken  of  separately. 

TABLE  68. 
Diseases  of  the  Gasfro-Enteric  Tract. 


GASTRIC. 


Developmental. 


NON-IXFECTIOCS . 


Functional 


Infectious 
r  Developmental 


EXTERIC. 


■{I 


Kon-Infectious.  j 


.  Infectious. 


Malpositions,  p.  770. 

Mechanical....  |  Contraction,  p.  772. 
*■  Dilatation,  p.  773.. 

Ulcers Peptic,  p.  777. 

New  growths,  p.  777. 

f  Nervous  vomiting,  p.  778. 
Recurrent  (periodic)  vom- 
iting, p.  778. 
[  Indigestion,  p.  782. 

Traumatic Corrosive  gastritis,  p.  787. 

Gastritis,  p.  787. 
Jilalpositions,  p.  790. 
Malformations,  p.  790. 

Dilatation  of  colon,  p.  791. 
Volvulus,  p.  792. 
Intussusception,  p.  792, 
Hernia,  p.  794. 
Fissure,  p.  794. 
Prolapse,  p.  795. 
Hemorrhoids,  p.  795. 
795. 

f  Incontinence,  p.  798. 
I  Constipation,  p.  798. 
Nervous  diarrhoea,  p.  801. 

r  Duodenal,  p.  803. 
Indigestion -j  J^^gg^JnJJl  f  Deficient  secretion,  p.  807. 
*-  1  Fermentation,  p.  808. 

f  Dysentery,  p.  815. 
Infectious  diarrhoea.  .)  cholera  infantum,  p.  823. 
Proctitis,  p.  826.  j^  Other  organisms,  p.  815. 

Appendicitis,  p.  826. 
Fistulse,  p.  831. 


f  Mechanical. 


New  growths,  p. 


Functional . . 


INTESTINAL  WORMS,  p.  831. 


DISEASES  OF  THE  STOMACH. 

Diseases  of  the  stomach  are  in  a  large  majority  of  cases  in  infants  and 
young  children  of  a  functional  character,  pronounced  organic  lesions 
being  rare.  Very  little  is  known  about  the  bacteria  of  the  stomach,  and  in 
comparison  with  those  of  the  intestine  they  are  far  less  numerous.  As 
the  only  symptom  which  points  directly  to  the  stomach,  vomiting,  occurs 
very  frequently  from  reflex  causes  when  the  intestine  alone  is  involved, 
the  greatest  caution  should  be  used  in  making  a  diagnosis  of  purely  gastric 
disease.  Diseases  of  the  stomach  may  arise  from  developmental,  non- 
infectious and  infectious  causes. 

I.  Developmental. — Under  developmental  diseases  of  the  stomach  are 
included  malpositions  and  malformations. 

A  malposition  of  the  stomach  may  be  met  with  in  various  places,  one 
of  which  is  in  the  thoracic  cavity^  They  are  very  rare  and  are  of  ana- 
tomical rather  than  of  clinical  interest,  as  the  diagnosis  can  scarcely  be 
made  during  life. 

Malformations  of  the  stomach  are  represented  by  a  narrowing  of  either 


DISEASES   OF   THE   STOMACH. 


771 


the  cardiac  or  pyloric  orifice  of  the  stomach  or  by  a  constriction  in  various 
parts  of  the  ventral  cavity  (hour-glass  contractions). 

The  most  common  malformation  of  the  stomach  is  a  stenosis  of  the 
pylorus,  and  is  the  one  which  has  become  so  prominent  that  it  should  be 
especially  described. 

STENOSIS   OF   PYLORUS. 

This  condition  was  first  mentioned  by  Beardsley  of  New  Haven,  Con- 
necticut, in  1788.  The  first  systematic  record  of  cases  was  made  by 
Hirschsprung  of  Copenhagen,  in  ]  888.  An  exhaustive  review  of  the  sub- 
ject was  published  by  Scudder  and  Quinby  in  1905,  and  we  are  indebted 
to  these  authors  for  our  latest  information  on  the  subject.  The  condition 
is  a  congenital  one. 

Pathological  Anatomy. — The  chief  anatomical  condition  which  causes 
the  enlargement  and  the  resulting  pyloric  tumor  is  a  hyperplasia  of  the 
circular  muscular  fibres  of  the  pylorus.  The  longitudinal  fibres  are  some- 
times found  increased  in  size  and  the  muscularis  mucosae  is  at  times 
thicker  than  normal  and  frequently  thrown  into  folds. 

Although  the  lumen  of  the  pylorus  may  vary  normally  in  different  in- 
dividuals of  the  same  age  yet  for  purposes  of  comparison  Pfaundler's  table, 
giving  the  measurements  of  the  normal  pylorus  from  birth  to  twelve 
months,  is  valuable : 

TABLE  69. 

Pfaundler's  index,  showing  the  diameter  of  the  lumen  of  the  pylorus  in  m.  m.,  according  to  the 

French  scale  of  urethral  sounds. 


Age. 

m.  m. 

Charriere. 

Age. 

m.  m. 

Charriere. 

Birth 

...       6.3 

19 

7  months 

. . .       8.9 

27 

1  month 

6  9 

21 

22 

8  months  .... 

9  months  .... 

...       9.2 

. ..       9.5 

28 

2  months 

...       7.3 

29 

3  months 

...       7.6 

23 

10  months 

...       9.8 

30 

4  months 

. ..       7.9 

24 

1 1  months  .... 

. . .     10.1 

31 

5  months 

. ..       8.2 

25 

12  months  .... 

. . .     10.5 

32 

6  months 

. . .       8.5 

26 

The  stenosis  is  probably  greater  in  life  than  that  found  at  autopsy. 

Symptoms. — The  stenosis  may  be  complete  or  partial,  and  the  resulting 
symptoms  vary,  according  to  the  degree  of  the  stenosis.  The  group  of 
symptoms  which  when  present  enables  us  to  make  a  diagnosis  are  vomit- 
ing, rapid  emaciation,  a  tumor  in  the  region  of  the  pylorus,  and  absence  of 
or  a  very  slight  amount  of  fsecal  movements  :  later,  a  dilated  stomach,  and 
in  some  cases  visible  gastric  peristalsis.  The  vomiting  usually  begins 
within  three  weeks  after  birth.  It  may  begin  on  the  first  day.  In  fifty- 
two  cases  the  average  beginning  was  on  the  seventeenth  day.  The 
vomiting  is  usually  expulsive  and  may  occur  immediately  after  feeding,  or 
be  delayed  for  half  an  hour  or  longer.     When  the  stenosis  is  complete 


772  .  PEDIATRICS. 

there  is  absence  of  bile  in  the  vomitus.  When  the  stenosis  is  partial 
there  may  be  a  remission  of  the  vomiting  for  several  days.  It  is  probable, 
especially  in  the  partial  cases,  that  spasmodic  contractions  take  place,  and 
by  contracting  and  relaxing,  give  rise  to  exacerbations  and  remissions  of 
the  symptoms  and  make  the  diagnosis  still  more  difficult.  The  tumor 
often  cannot  be  detected.  An  enlarged  lymph-node  may  simulate  a  pyloric 
tumor.  A  moderate  stenosis  may  be  attended  by  great  wasting  (Scudder). 
There  is  usually  great  hunger  and  no  nausea. 

Diagnosis. — All  the  other  causes  of  vomiting  (see  page  778)  must  be 
considered  before  the  diagnosis  of  stenosis  is  accepted.  Vomiting  is  so 
common  from  indigestion  that  every  case  should  at  once  be  treated  by  the 
most  approved  rules  of  modern  feeding,  including  considerable  doses  of 
alkalies  to  relieve  spasm.  Only  when  this  has  failed  should  the  diagnosis 
of  pyloric  stenosis  be  accepted  so  far  as  to  justify  an  exploratory  laparot- 
omy. The  cases  of  recurrent  vomiting,  as  a  rule,  do  not  occur  so  early 
in  life,  run  a  short  course,  present  continuous  vomiting  irrespective  of  the 
introduction  of  food  into  the  stomach,  and  are  not  accompanied  by  a 
pyloric  tumor.  It  must  be  allowed  that  the  stenosis  may  be  in  the  upper 
intestine,  rather  than  in  the  stomach. 

Prognosis.— It  is  probable  that  cases  of  partial  stenosis  may  survive 
the  early  months  and  even  years  of  life,  and  may  in  childhood  be  the  only 
cause  of  digestive  disturbance.  Surgical  statistics  show  that  the  mortality 
percentage  in  the  cases  operated  on  is  about  47.7.  According  to  Monnier 
the  cases  not  operated  on  show  a  mortality  of  80  per  cent.  The  youngest 
case  operated  on  and  recovering  up  to  1906  was  reported  by  us.  It  was 
a  male,  three  weeks  old,  operated  on  by  Munro. 

Treatment. — The  treatment  is  essentially  surgical.  Posterior  gas- 
tro-enterostomy  is  considered  the  best  operative  procedure. 

II.  Non-Infectious.^ — The  non-infectious  diseases  of  the  stomach  may 
be  divided  into  mechanical,  ulcers,  new  growths,  functional  and  traumatic. 

MECHANICAL. 

Mechanical  diseases  of  the  stomach  are  represented  by  contraction  and 
dilatation. 

CONTRACTION   OP  THE   STOMACH. 

In  certain  cases  the  gastric  capacity  of  the  stomach  is  decidedly  dimin- 
ished. The  diminution  in  size,  as  a  rule,  depends  upon  a  lack  of  use, 
such  as  occurs  in  infantile  atrophy.  Sufficient  food  to  fill  the  stomach  is 
not  taken,  and  in  this  way  the  stomach  is  not  called  upon  to  perform  its 
normal  work.  In  cases,  also,  in  which  there  is  continuous  vomiting,  this 
same  lack  of  use  may  produce  a  diminution  in  the  size  of  the  stomach. 
These  cases  are  of  pathological  rather  than  of  clinical  interest,  as  they  can 
seldom  be  diagnosticated,  and  their  treatment  is  essentially  that  of  the 
especial  disease  to  which  they  are  secondary. 


DISEASES   OF  THE   STOMACH.  773 

DILATATION   OF  THE   STOMACH. 

A  moderate  dilatation  of  the  stomach  is  rather  more  common  in 
infancy  than  in  older  children.  The  higher  degrees  of  dilatation  are  rare. 
It  may  rarely  arise  from  some  malformation,  such  as  a  stenosis  of  the 
pylorus,  but  in  most  cases  is  the  result  of  errors  in  feeding.  It  is  more 
apt  to  occur  when  the  infant  is  not  nursed,  unless  especial  care  is  taken 
to  give  it  the  cjuantity  of  food  which  is  adapted  to  its  age  and  gastric 
capacity.  When  the  infant  is  nursed,  the  breast  seems  to  provide  the 
amount  of  food  which  is  suitable.  Dilatation  from  errors  in  feeding 
may  be  caused  by  the  fact  that  the  food  is  not  adapted,  either  in  quality 
or  in  quantity,  to  the  age  of  the  individual  infant.  When  the  quality  is 
at  fault,  the  nutrition  of  the  tissues  of  the  stomach  is  interfered  with,  and 
its  walls  become  weak,  and  are  thus  more  easily  distended  by  the  gas 
which  results  from  the  abnormal  changes  in  the  food.  In  this  way  dila- 
tation occurs.  This  class  of  cases  is  notably  represented  in  the  disease 
rhachitis,   in   which  dilatation  of  the  stomach  takes  place  very  readily. 

When  the  quantity  of  the  food  is  not  properly  adapted  to  the  size  of 
the  stomach,  dilatation  can  take  place  in  even  a  healthy  infant,  so  that 
the  careful  regulation  of  the  amount  of  food  which  is  given  at  each  feeding 
during  the  first  year  of  life  is  most  important. 

Pathological  Anatomy. — The  pathological  condition  which  exists  in 
cases  of  gastric  dilatation  is  well  represented  in  Fig.  160. 

Symptoms. — The  symptoms  of  dilatation  of  the  stomach  are  essentially 
those  of  chronic  indigestion.  Vomiting  is  quite  frequent,  and  continues 
until  the  stomach  has  been  entirely  emptied,  when  a  period  of  relief  comes, 
to  last  until  fresh  irritation  arises  from  another  supply  of  food.  Abdomi- 
nal pain,  flatulence,  and  general  discomfort  are  prominent  symptoms. 
Rapid  loss  in  weight  and  emaciation  also  occur.  In  some  cases,  in  young 
infants,  convulsions  may  arise,  apparently  due  to  the  reflex  disturbance 
which  is  produced.  There  are  usually  considerable  thirst  and  loss  of  ap- 
petite. When  the  dilatation  is  of  a  high  grade,  the  vomiting  may  occur 
only  after  considerable  intervals, — twenty-four  to  forty-eight  hours, — 
during  which  time  the  food  does  not  pass  out  through  the  pyloric  orifice 
to  any  degree,  but  collects  in  the  stomach. 

Under  normal  conditions  the  stomach  is  somewhat  tubular  in  shape 
and  oblique  in  position.  The  food  thus  easily  passes  through  the  cardiac 
to  the  pyloric  orifice.  In  dilatation  of  the  stomach,  on  the  contrary,  the 
greater  curvature  is  so  much  increased  and  depressed  below  the  level  of 
the  pyloric  orifice  that  a  pouch  is  formed.  The  food,  collecting  in  this 
pouch  as  though  it  were  at  the  bottom  of  a  well,  has  to  be  practically 
pumped,  by  the  contraction  of  the  muscular  walls,  up  to  and  through  the 
pyloric  orifice.  The  already  weakened  stomach  thus  has  to  perform  work 
for  which  it  is  not  fitted,  and  finally  is  relieved  by  spasmodic  vomiting. 
When  only  the  small  amount  of  food  adapted  to  their  normal  gastric 
capacity  is  given  to  young  infants  whose  stomachs  are  dilated,  a  large  space 


774 


PEDIATRICS. 


of  empty  stomach  is  left  above  the  level  of  the  liquid  which  has  entered 
the  stomach.  This  creates  a  feeling  of  emptiness  and  general  discomfort, 
so  that  the  infant  appears  to  be  hungry  when,  in  fact,  it  is  only  suffering 
from  the  feeling  of  incomplete  filling  of  the  stomach. 

This  stomach  was  taken  from  an  artificially  fed  rhachitic  infant,  seven  months  old, 
who  died  under  our  care  at  the  Boston  City  Hospital.  The  gastric  capacity  in  this  case 
was  300  c.  c.  (10  ounces),  which  corresponds  to  the  gastric  capacity  of  an  infant  twelve 
months  old.     The  shape  of  the  stomach  is  very  significant  of  the  symptoms. 

The  lesser  curvature  is  not  much  altered,  while  the  greater  curvature  is  very  much 
increased.     The  pathological  condition  of  the  tissues  in  these  cases  is  such  as  would  be 


Fig.  160. 


Dilated  stomach.    Rhachitic  infant,  7  months  old     (Actual  size.) 


expected  from  general  malnutrition.     In  such  diseases  as  rhachitis  there  is  a  stretch- 
ing of  the  muscular  fibres,  as  well  as  an  atrophied  condition  of  the  entire  gastric  walls. 

On  inspection  the  abdomen  is  seen  to  be  distended  and  tense,  and  on 
percussion  to  be  highly  tympanitic  in  its  upper  part.     Succussion  is  not 


DISEASES   OF   THE   STOMACH.  775 

an  especially  valuable  diagnostic  sign  in  dilatation  of  the  stomach.  Suc- 
cussion  is  so  frequently  found  in  many  conditions,  and  is  so  likely  to  be 
confounded  with  that  which  occurs  in  the  colon,  that  it  cannot  be  rehed 
upon.  The  outlines  of  a  normal  stomach  when  it  is  somewhat  distended 
vary  so  much  during  infancy  that  the  results  of  percussion  are  often  very 
misleading.  When,  however,  the  tympanitic  resonance  is  found  to  ex- 
tend below  the  line  of  the  umbilicus,  we  may  suspect  that  we  are  deal- 
ing with  gastric  dilatation,  but  even  then  it  is  uncertain  whether  it  is 
the  gastric  tympany  which  we  have  obtained.  In  infancy  the  cardiac 
end  of  the  stomach  is  so  slightly  developed  that  any  great  increase  in 
the  area  of  gastric  resonance  on  the  left  side  is  an  important  aid  in 
making  the  diagnosis. 

Diagnosis. — The  differential  diagnosis  is  to  be  made  chiefly  from  dila- 
tation of  the  colon.  In  many  cases  when  the  colon  is  dilated  it  is  impos- 
sible to  determine  whether  the  stomach  is  also  dilated,  since  under  these 
circumstances  the  colon  can  almost  completely  cover  a  largely  dilated 
stomach.  In  cases  in  which  the  diagnosis  is  uncertain,  a  valuable  means  of 
determining  the  presence  of  dilatation  is  artificial  distention.  This  can  be 
done  without  harm  or  much  discomfort  to  the  child  by  filling  the  stomach, 
several  hours  after  the  last  feeding,  by  gas  generated  by  giving  part  of  a 
seidlitz  powder  in  divided  portions,  by  air  through  a  stomach-tube,  or  pref' 
erably  by  water. 

The  gastro-diaphane,  recommended  by  Koplik,  can  also  be  used  as  a 
method  of  diagnosis. 

Prognosis. — If  the  dilatation  is  due  to  congenital  stenosis  of  the 
pylorus  the  prognosis  is  that  of  stenosis.  In  other  cases  the  prognosis 
depends  upon  whether  the  condition  arises  from  improper  amounts  of 
food  or  from  some  disease,  such  as  rhachitis.  In  the  former  class  the 
prognosis  is  good,  and  the  stomach  under  a  proper  regulation  of  the  diet 
soon  resumes  its  natural  size.  In  the  second  class  it  is  not  so  good,  and, 
as  a  rule,  the  stomach  will  remain  more  or  less  distended  until  the  disease 
which  causes  the  dilatation  has  been  cured. 

Treatment. — If  the  case  is  an  obstinate  one,  lavage  is  an  important 
part  of  the  treatment.  In  many  cases,  however,  good  results  are 
obtained  simply  by  regulating  the  quality  and  quantity  of  the  food. 
When  the  food  is  first  given  in  the  proper  amount  it  will  not  fill  the 
stomach  nor  satisfy  the  demands  of  the  infant.  Under  these  circum- 
stances the  infant  will  be  very  restless,  and  will  often  cry  almost  continu- 
ously from  the  time  of  one  feeding  until  the  next.  The  nurse  must  be 
made  to  understand  that  these  signs  of  discomfort  are  liable  to  last  for  a 
number  of  days,  until  the  stomach  has  more  nearly  resumed  its  normal 
size,  and  that  an  additional  supply  of  food  must  not  be  given  to  the  infant 
because  it  cries  for  more. 

The  following  case  illustrates  dilatation  of  the  stomach  as  it  occurs  in  the  first  year 
of  life.     A  male  infant  four  months  old  was  well  and  strong  at  birth.     It  was  not  nursed, 


776 


PEDIATRICS. 


but  was  fed  on  a  mixture  of  milk,  cream,  and  water.  It  was  unusually  vigorous,  and  is 
reported  to  have  never  been  satisfied  with  the  small  quantities  of  food  suitable  to  its  age. 
When  it  was  three  weeks  old  it  was  given  150  to  180  c.c.  (5  or  6  ounces)  at  each  meal. 
Somewhat  later,  in  its  second  and  third  months,  it  gradually  developed  symptoms  of  in- 
digestion, and  when  we  were  called  to  see  it  was  in  a  very  serious  condition.  It  had  been 
having  frequent  and  prolonged  convulsions.  At  times  when  it  was  in  the  convulsions  it 
would  fall  into  a  state  of  collapse,  the  pallor  of  its  face  would  be  extreme,  and  it  would 
look  as  though  it  were  dying.  On  examination  nothing  abnormal  was  found  in  the 
thorax.     The  entire  abdomen  was  found  to  be  distended,  especially  in  the  upper  part, 


Fig.  IGl. 


L)ilatation  of  stomacli.    Age,  G  years. 


where  the  gastric  tympany  was  pronounced  and  easily  marked  out  by  percussion.  The 
percussion  showed  the  stomach  to  be  dilated,  and  to  extend  below  the  line  of  the  um- 
bilicus and  far  to  the  left  of  the  median  line. 

The  infant  was  given  small  amounts  of  food  at  frequent  intervals.  For  the  first 
two  or  three  days  it  cried  and  screamed  for  more  food,  but  the  convulsions  ceased,  its 
general  condition  improved,  by  the  end  of  the  week  the  distention  of  the  stomach  had 
subsided  very  markedly  and  the  infant  had  become  tranquil,  and  this  time  there  was  no 
recurrence  of  the  symptoms. 

A  second  case  was  that  of  a  colored  boy  six  years  old.   (Fig,  161.)    He  was  markedly 


DISEASES   OF   THE  STOMACH.  777 

rhachitic.  He  was  reported  to  have  been  in  fair  health,  though  deUcate,  until  one  month 
previous  to  entering  the  hospital,  when  he  began  to  have  persistent  vomiting.  He  had 
lost  greatly  in  weight,  had  been  very  restless  at  night,  and  he  had  continual  borborygmi. 

Physical  examination  showed  marked  abdominal  enlargement.  On  percussion  the 
gastric  tympany  was  found  to  extend  downward  as  far  as  the  umbilicus,  7. 8  cm.  (3  inches) 
to  the  right  of  the  median  line,  and  10.4  cm.  (4  inches)  to  the  left.  In  the  figure  the 
line  of  percussion  which  represents  the  greater  curvature  of  the  stomach  is  marked  with 
white  dots.  As  the  resonance  of  the  colon  was  also  exaggerated  in  this  case,  and  as  its 
differentiation  from  that  of  the  stomach  was  somewhat  difficult  because  it  evidently  over- 
lapped the  lower  border  of  the  stomach,  an  endeavor  was  made  to  eliminate  this  obstacle 
to  diagnosis  by  mechanical  means.  The  child  was  given  one-half  a  seidlitz  powder  dis- 
solved in  water.  The  other  half,  which  had  also  been  dissolved  in  water,  was  next 
swallowed.  The  child  showed  no  signs  of  discomfort,  and  stated  that  he  did  not  feel  any 
pain  or  any  more  tenderness  in  the  epigastrium  than  before  the  powders  were  taken. 
The  outline  of  the  distended  stomach  could  be  fairly  well  seen,  and  on  percussion  the 
line  of  the  greater  curvature  was  found  to  be  2.5  cm.  (1  inch)  below  the  line  of  the 
umbilicus,  the  colon  having  been  pushed  out  of  the  way  by  the  distended  stomach. 
We  have  indicated  the  line  of  greater  curvature  by  a  broad  white  line. 

(Subsequent  history.)  In  this  case  it  was  not  found  necessary  to  wash  out  the 
stomach  more  than  once  or  twice,  for  as  soon  as  small  amounts  of  food  were  given  at 
frequent  intervals  the  vomiting  ceased  and  the  stomach  gradually  resumed  its  normal 
size.  At  the  end  of  two  months  the  child  left  the  hospital  free  from  any  abnormal  gas- 
tric symptoms. 

ULCERS. 

Ulcers  of  the  stomach  in  infancy  and  early  childhood  are  very  rare, 
but  cases  have  been  reported.  When  non- infectious  they  correspond  to 
the  ordinary  peptic  ulcer  of  later  life.  There  are  no  diagnostic  symptoms, 
and  sometimes  no  symptoms  until  perforation  has  occurred  ;  when,  how- 
ever, there  is  vomiting  of  blood,  ulceration  may  be  suspected. 
-The  prognosis  is  bad. 

The  treatment  is  necessarily  symptomatic  and  consists  of  rest  from 
food,  ice,  nutrient  enemata,  and,  if  symptoms  of  perforation  appear,  of 
exploratory  laparotomy, 

NEW  GROWTHS. 
Morbid  growths  in  the  stomachs  of  infants  and  young  children  are  so 
extremely  rare  that  their  occurrence  need  merely  be  referred  to.  Finlay- 
son  has  reported  a  primary  case  of  sarcoma  at  three  and  a  half  years. 
Polleston  and  Latham  have  reported  a  case  of  multiple  lymphadenoma  in 
a  rhachitic  infant  eighteen  months  old.  Osier  and  McCrse  collected  and 
reported  in  the  New  York  Medical  Journal,  April  21,  1900,  six  cases  of 
cancer.  Four  of  these  were  in  young  infants  and  probably  were  con- 
genital ;  the  other  two  were  under  ten  years  of  age. 

FUNCTIONAL. 
Functional  diseases  of  the  stomach  are  represented  by  {a)  nervous 
vomiting,  (6)  recurrent  vomiting,  (c)  and  indigestion.     In  the  vast  majority 
of  cases  vomiting  in  infants  and  young  children  is  functional.    As  vomiting 


778  PEDIATRICS. 

is  a  very  common  symptom  in  many  diseases  besides  those  of  the  stomach, 
it  is  well  to  bear  in  mind  the  various  causes  of  vomiting  before  speaking 
in  detail  of  certain  types  which  practically  should  be  described  under 
functional  diseases  of  the  stomach. 

Owing  to  the  comparatively  tubular  shape  of  the  stomach  and  its 
position  in  the  abdomen  in  mfants,  regurgitation  from  overfilling  and  dis- 
tention is  very  common.  Obstruction  and  misplacements,  whether  in  the 
stomach  or  intestine,  and  irritation  of  any  kind  in  the  gastro-enteric  tract, 
as  well  as  inflammatory  conditions  of  the  peritoneum,  are  frequently  ac- 
companied by  vomiting.  Vomiting  is  a  common  initial  symptom  in  many 
of  the  acute  infections,  as  in  the  exanthemata  and  the  pneumonias,  and 
seems  to  be  caused  at  times  by  the  direct  elimination  of  toxines.  In  certain 
infants  and  children  vomiting  seems  to  depend  on  habit.  Too  great 
rapidity  in  nursing,  handling  the  infant  after  nursing,  adenoids  and  cleft 
palates,  are  frequent  causes  of  vomiting.  In  addition  to  the  causes  just 
mentioned,  innumerable  cases  of  vomiting  arise  from  diseases  of  the  central 
nervous  system,  such  as  the  cerebral  vomiting  occurring  in  meningitis,  and 
from  cerebral  tumors  and  the  reflex  action  connected  with  irritation  from 
the  ear,  throat,  nose  and  teeth.  In  most  of  these  cases  the  vomiting  is  a 
symptom  of  some  morbid  condition  outside  of  the  stomach,  and  should  be 
studied  and  treated  under  the  disease  which  it  represents. 

Nervous  Vomiting-. — Another  type  of  vomiting  wliich  seems  to  be 
closely  connected  with  the  stomach  itself,  but  not  dependent  on  any 
organic  disease  of  the  stomach,  has,  for  want  of  a  better  name,  been  called 
nervous.  In  these  cases  the  function  of  the  stomach  has  been  disturbed 
by  general  nervous  conditions,  such  as  heat,  cold,  fright,  and  possibly 
foreign  bodies,  including  undigested  food. 

Treatment, — As  a  rule  no  internal  remedies  are  indicated,  except  a 
decrease  in  the  strength  of  the  milk  and  an  increase  in  its  alkalinity.  If 
possible  the  exciting  cause  should  be  removed  and  the  stomach  given 
complete  rest  until  the  ner\-ous  disturbance  has  subsided. 

Recurrent  Vomiting-. — (Periodic.) — This  form  of  vomiting  is  of  such 
^clinical  significance  that  it  must  be  described  as  a  disease  by  itself.     It  has 
not  yet  been  proved  that  it  is  a  primary  disturbance  of  the  stomach. 

It  is  possible  that  the  source  of  irritation  is  entu-ely  outside  of  the 
stomach,  and  perhaps  connected  with  the  great  sympathetic  ganglia,  such 
as  the  solar  plexus.  It  may,  however,  ultimately  be  shown  to  be  of  toxic 
origin  and  to  be  caused  by  the  elimination  of  toxines  into  the  stomach 
itself,  or  by  their  action  on  the  central  nervous  system. 

Etiology. — The  exciting  cause  of  the  vomiting  in  most  cases  is  obscure, 
but  is  evidently  very  varied.  It  does  not  seem  to  be  produced  especially 
by  errors  of  diet,  but,  on  the  contrary,  occurs  in  children  whose  diet  has 
been  most  carefully  regulated.  Undue  exposure  to  cold,  fright,  and  ex- 
citement all  appear  to  have  sometimes  an  etiological  influence  on  the  dis- 
ease.    Investigations  by  Marfan  and  by  Edsall  on  acetonemia  point  strongly 


DISEASES   OF   THE  STOMACH.  779 

to  acid  intoxication  as  a  factor  in  the  etiology.  The  odor  of  acetone  in  the 
urine  immediately  before  an  attack  is  not  uncommon,  and  oxybutyric  and 
diacetic  acids  in  conjunction  with  acetone  have  been  found  in  the  urine. 
It  is  significant,  however,  that  this  does  not  occur  in  all  cases,  and  that  it 
may  occur  in  cases  where  recurrent  vomiting  is  not  present  as  in  diabetes. 
This  form  of  vomiting  may  occur  at  any  age.  We  have  met  with  cases  in 
young  infants  and  throughout  the  whole  period  of  childhood,  sometimes 
lasting  until  adult  life.  The  attacks  may  occur  not  only  in  delicate  but  in 
vigorous  children. 

Symptoms. — The  attack  is  very  apt  to  come  on  suddenly,  the  child 
being  previously  in  good  health  and  not  having  shown  any  digestive  dis- 
turbance. The  period  over  which  the  disease  extends  and  the  intervals 
of  the  vomiting  during  the  attack  vary  considerably,  but  in  those  cases 
which  have  come  under  our  notice  they  are  somewhat  as  follows:  The 
child,  without  any  especial  warning,  begins  to  vomit,  and  at  first  the 
vomitus  will  simply  be  the  remains  of  food  which  still  happen  to  be  in 
the  stomach.  It  will  continue  to  vomit  quite  regularly  every  fifteen  or 
thirty  minutes.  This  may  last  for  ten  or  twelve  hours  ;  the  intervals  then 
grow  longer,  and  sometimes  the  vomiting  will  cease  for  twelve  or  fifteen 
hours,  and  then  begin  again.  Occasionally  a  little  mucus,  and,  as  the  dis- 
ease progresses,  a  slight  amount  of  bile  usually  appear  in  the  vomitus. 
A  very  prominent  symptom  is  thirst,  the  child  crying  continually  for  water, 
and  vomiting  it  soon  after  it  is  taken.  As  a  rule,  the  temperature  in  these 
cases,  although  at  times  somewhat  elevated  is  usually  normal  or  subnormal. 
The  pulse  varies,  but  is  very  apt  to  be  slow,  sometimes  intermittent,  and 
becomes  weak.  After  the  first  twenty-four  hours  the  child  emaciates 
rapidly,  looks  very  ill,  and  becomes  apathetic,  and  the  temperature  often 
becomes  elevated. 

Unless  the  disease  is  unwisely  treated  by  endeavoring  to  introduce 
food  or  drugs  into  the  stomach,  it  will  usually  prove  to  be  self-limited, 
and  will  run  its  course  in  two  or  three  days.  In  some  cases  the  length 
of  the  attack  is  much  shorter,  being  comprised  within  twenty-four  hours, 
while  in  others  it  may  last  for  many  days.  The  recovery  is  often  sudden. 
As  soon  as  the  vomiting  has  stopped,  the  appetite  returns  ;  there  are  no 
special  symptoms  of  indigestion ;  the  child  takes  its  food  well,  and  the 
emaciation  disappears  rapidly.     Relapses  occasionally  take  place. 

Diagnosis. — The  diagnosis  of  this  form  of  vomiting  is  often  difficult, 
more  on  account  of  a  lack  of  sufficient  knowledge  concerning  the  dis- 
ease than  from  much  evidence  of  the  existence  of  the  diseases  which  it 
is  supposed  to  simulate.  Thus  in  early  infancy  acute  persistent  vomit- 
ing may  be  the  first  symptom  of  a  beginning  tubercular  meningitis.  In 
these  cases  an  examination  of  the  abdomen  should  be  made  at  once,  in- 
cluding a  rectal  examination.  This  is  necessary  in  order  to  exclude  such 
sources  of  vomiting  as  volvulus,  intussusception,  and  appendicitis.  Cases 
of  periodic  or  persistent  vomiting  in  young  cliildren  simulate  very  closely 


780  PEDIATRICS. 

the  onset  of  acute  appendicitis.  The  absence  of  any  marked  increase  in 
the  temperature  and  a  careful  examination  of  the  thorax  will  in  most  cases 
exclude  the  sudden  onset  of  some  pulmonary  disease  or  of  the  acute 
infectious  diseases.  The  disease  which  is  most  commonly  suspected  in 
these  cases  is  tubercular  meningitis,  and  in  the  beginning  of  the  attack  it 
is  often  impossible  to  differentiate  the  two  diseases,  as  in  some  cases 
vomiting  is  the  only  symptom  of  a  tubercular  meningitis.  In  recurrent 
vomiting  the  face  and  general  appearance  of  the  child  indicate  nausea 
rather  than  the  apathy  which  would  be  present  in  tubercular  meningitis. 
The  mind  also,  in  contradistinction  to  what  takes  place  in  the  latter  disease, 
is  clear,  the  child  remaining  cjuiet  merely  because  it  is  exhausted.  The 
great  thirst  which  has  been  already  mentioned  as  being  present  in  per- 
sistent vomiting  also  aids  materially  in  the  differential  diagnosis  from 
tubercular  meningitis.  The  sudden  onset  of  the  vomiting  in  a  previously 
healthy  child  in  the  middle  period  of  childhood  is  quite  different  from  the 
slow  progress  and  the  occasional  vomiting  of  a  cerebral  type  met  with  in 
tubercular  meningitis.  The  theory  of  acid  intoxication  suggests  an  ex- 
amination of  the  urine  for  acetone,  diacetic  acid,  and  oxybutyric  acid  as 
important  aids  to  diagnosis,  but  their  detection  is  not  necessarily  diag- 
nostic, nor  does  their  absence  preclude  the  presence  of  the  disease. 

After  the  first  twenty-four  hours,  this  disease  is  readily  differentiated 
from  attacks  of  simple  indigestion,  for,  when  the  vomiting  arises  from 
indigestion,  the  stomach  is  speedily  relieved,  and  the  vomiting  does  not 
continually  recur  without  apparent  cause,  as  in  recurrent  vomiting. 

Recurrent  vomiting  is  also  very  commonly  diagnosticated  as  acute 
gastric  catarrh,  but  in  the  latter  disease  the  heightened  temperature, 
coated  tongue,  pain,  and  tenderness  in  the  epigastrium  will,  after  the  first 
twenty-four  hours,  allow  us  to  differentiate  the  two  diseases. 

Prognosis. — The  prognosis  A^aries  according  to  the  age  of  the  individual 
affected.  In  young  infants,  especially  in  those  whose  vitality  is  weak,  it 
may  prove  to  be  a  very  serious  disease,  from  the  exhaustion  which  inva- 
riably arises  in  the  first  twenty-four  hours.  The  rule  is  that  the  younger 
/^  ihe  individual  the  more  prostrating  and  serious  is  the  disease.  Even  older 
children  are  at  times  so  prostrated  by  the  continuous  vomiting  that  grave 
doubts  are  often  entertained  as  to  their  ultimate  recovery.  In  general, 
however,  the  prognosis  in  these  cases  is  good,  and  we  have  never  seen  the 
disease  result  in  death. 

Treatment. — The  treatment  is  starvation  during  the  first  twenty-four 
hours.  If  an  attack  is  suspected  and  the  drug  can  be  given  before  vomit- 
ing begins,  bicarbonate  of  soda  in  doses  of  0.65  to  1.01  gramme  [gr. 
x-xv]  repeated  every  hour  until  the  urine  is  alkaline,  has  proved  of  value 
in  aborting  some  cases.  The  child  should  be  kept  perfectly  quiet  in  a 
darkened  room.  If  after  twenty-four  hours  the  vomiting  still  continues,  or 
even  before,  if  there  appears  to  be  much  exhaustion,  or  if  the  child  is  rest- 
less and  sleepless  and  has  an  intermittent  pulse,  hydrate  of  chloral  0.1 


DISEASES   OF   THE   STOMACH.  781 

gramme  [gr.  iss]  and  bromide  of  potassium  0.65  gramme  [gr.  x]  dissolved 
in  brandy  and  water,  should  be  given  by  the  rectum.  When  the  symptoms 
cannot  be  controlled  by  chloral  and  bromide,  morphia  .002  gramme 
[gr.  3^2]  for  a  child  of  five  years.  These  are  intended  to  procure  sleep  and 
to  stimulate  the  nervous  centres.  As  a  rule,  however,  the  child  is  quiet^ 
and  sleeps  in  the  intervals  of  vomiting,  and,  as  the  disease  usually  attacks 
an  infant  or  a  child  who  has  been  perfectly  well,  cardiac  weakness  is  not 
commonly  shown  in  the  first  forty-eight  hours.  No  food  and  no  drugs 
should  be  given  by  the  mouth.  If  the  vomiting  has  begun  very  large 
doses  of  bicarbonate  of  soda  should  be  given  to  combat  the  acid  intoxi- 
cation of  the  blood.  One  to  two  drachms,  according  to  the  age  of  the 
child,  well  diluted  and  in  divided  doses,  should  be  given  by  rectum  until 
the  urine  shows  an  alkaline  reaction.  The  dose  should  then  be  diminished 
and  given  in  quantities  just  sufficient  to  maintain  the  alkaline  reaction. 

When  the  thirst  is  very  great,  rehef  is  sometimes  obtained  by  high 
injections  of  from  4  to  6  ounces  of  salt  solution.  After  twenty-four  hours, 
small  enemata  of  peptonized  milk  can  be  given  including,  if  necessary, 
bromide  of  potassium  and  chloral.  Under  two  years  the  enemata  may 
contain  2  ounces,  and  from  four  to  five  years,  3  to  4  ounces  every  4  hours. 
When  the  disease  appears  to  have  run  its  course,  as  it  often  does  in  three 
or  four  days,  small  quantities  of  a  carefully  modified  alkaline  milk  can  be 
tried  cautiously  by  the  mouth.  A  cleansing  enema  should  be  given  once 
in  24  hours.  A  mistake  is  usually  made  in  the  treatment  of  the  disease 
in  feeding  by  the  mouth  too  early. 

The  following  cases  are  illustrative  of  this  disease : 

An  infant,  eight  months  old,  strong  and  healthy,  had  always  been  fed  on  the  milk 
of  a  wet-nurse.  Without  any  previous  symptoms  he  began  to  vomit,  and  continued  to 
vomit  every  fifteen  minutes  for  twelve  hours.  The  intervals  then  became  longer,  and 
the  vomiting  ceased  entirely  on  the  third  day  of  the  attack.  During  the  attack  he 
emaciated  rapidly,  so  that  he  seemed  to  be  in  the  last  stages  of  some  wasting  disease. 
He  lay  perfectly  quiet  and  slept  in  the  intervals  of  the  vomiting.  His  mind  was  clear. 
His  temperature  was  subnormal,  and  his  pulse  weak  and  intermittent.  He  was  treated 
by  rectal  enemata  of  brandy,  peptonized  milk,  and  bromide  of  potassium. 

He  had  several  attacks  of  this  kind  in  each  of  the  following  years  of  his  life  until 
he  was  five  or  six  years  old,  when  he  would  sometimes  go  for  six  months  or  a  year  with- 
out an  attack.  As  he  grew  older  the  attacks  became  less  severe,  and  when  he  was  ten 
years  old  they  ceased  entirely. 

Another  case  was  that  of  a  girl  twenty-two  months  old,  who  was  perfectly  well 
until  the  vomiting  began.  Her  pulse  was  slightly  accelerated  at  first  but  gradually  be- 
came slow  and  intermittent.  Her  temperature  was  normal.  During  the  first  four 
days  of  the  attack  the  vomiting  was  almost  continuous,  and  she  became  so  weak  and 
exhausted  on  the  fourth  day  that  it  was  feared  she  might  die  suddenly.  There  were 
great  restlessness,  dilated  pupils,  throwing  of  the  head  backward,  slow  pulse,  and 
normal  respirations.  The  emaciation  was  rapid.  The  urine  was  scanty.  On  the  fifth 
day,  the  vomiting  having  continued,  she  fell  into  a  state  of  collapse,  the  pulse  was 
hardly  perceptible,  her  countenance  was  ghastly  and  her  extremities  were  cold.  At 
one  time  after  a  severe  attack  of  vomiting  she  became  cyanotic,  and  was  almost  stifled 


782  PEDIATRICS. 

by  tenacious  mucus.  Some  of  this  mucus  entered  the  larynx  during  the  attacks  of 
vomiting,  so  that  it  seems  as  though  her  life  was  saved  a  number  of  times  by  the 
prompt  action  of  an  experienced  nui'se.  On  the  sixth  day  the  vomiting  grew  less,  and 
on  the  seventh  day  it  ceased.  She  was  not,  however,  able  to  be  up  and  about  until 
the  eleventh  day,  and  was  not  fully  well  until  the  third  week  from  the  time  that  she 
was  attacked.     The  treatment  in  this  case  was  the  same  as  that  just  described. 

INDIGESTION. 

By  indigestion  we  mean  a  disturbance  of  the  gastric  secretions  inter- 
fering with  tlie  function  of  the  stomach  to  such  a  degree  as  to  cause  mor- 
bid symptoms.  The  secretions  may  be  absohitely  or  relatively  diminished. 
The  condition  may  be  acute  or  chronic. 

ACUTE  GASTRIC  INDIGESTION.     (Acute  Dyspepsia.) 

The  cause  of  acute  indigestion  in  infants,  and  in  almost  every  case  in 
young  children,  is  the  food  which  is  given  to  them.  This  is  especially 
noticeable  in  the  first  year.  The  ages  in  which  indigestion  most  fre- 
quently occurs  in  this  period  are,  first,  in  the  early  days  of  life,  when  the 
ec[uilibrium  of  the  breast-milk  has  not  been  established ;  second,  in  the 
middle  of  the  first  year,  when  the  breast-milk  is  so  apt  to  be  replaced  or 
supplemented  by  some  other  food ;  and,  third,  at  the  end  of  the  year, 
when  entirely  new  articles  of  diet  are  usually  given  to  the  infant. 

Symptoms. — The  symptoms  of  acute  indigestion  are  pallor,  nausea, 
eructations  of  gas,  a  general  appearance  of  discomfort,  due  probably  to 
the  pain  induced  by  the  development  of  gas  in  the  stomach,  with  its 
resulting  distention,  and  finally  with  moderate  or  severe  vomiting.  If  the 
diet  is  exclusively  of  milk,  the  vomitus  will  usually  contain  large  curds  of 
the  coagulated  proteids.  In  connection  with  the  gastric  disturbance  there 
is  commonly  constipation,  although  sometimes  there  may  be  a  relaxed 
condition  of  the  bowels.  The  faecal  discharges  accompanying  these  attacks 
are  of  an  abnormal  color,  usually  a  mixture  of  green,  white,  and  yellow, 
and  of  sour  odor.  There  is  little  or  no  fever.  At  times  the  symptoms 
are  so  severe  that  the  infant  looks  as  though  it  were  going  to  die.  In  rare 
cases,  also,  reflex  symptoms  of  a  serious  aspect  may  arise,  such  as  have 
been  described  under  asthma  dyspepticum  (page  946). 

Diagnosis. — Sometimes  the  diagnosis  is  obscured  by  the  absence  of 
vomiting,  but  the  pallor  and  nausea  are  usually  of  sufficient  prominence 
to  allow  us  to  decide  that  the  seat  of  the  disturbance  is  in  the  stomach. 
The  differential  diagnosis  is  most  important  between  this  condition  and 
acute  gastritis.  Acute  indigestion  is  much  more  common,  its  duration  is 
shorter,  there  is  less  fever,  tenderness  is  unusual,  and  the  response  to 
treatment  is  much  more  rapid  and  evident. 

Prognosis. — The  prognosis  of  acute  gastric  indigestion  is  in  most  cases 
good,  but  in  infants  whose  vitality  is  extremely  low,  or  in  those  that  are 
debilitated  by  some  wasting  disease,  these  attacks  are  of  serious  import, 
and  may  prove  fatal. 


DISEASES   OF  THE   STOMACH.  783 

Treatment. — The  treatment  of  acute  gastric  indigestion  is  to  empty 
the  stomach,  either  by  washing  it  out  or  by  the  administration  of  warm 
water.  A  mild  laxative  should  be  given  in  order  to  clear  away  the  undi- 
gested food,  and  the  diet  should  be  regulated.  The  laxative  may  be  4  to  8 
c.c.  (1  or  2  drachms)  of  castor  oil,  .007  to  .006  gramme  (one-eighth  to  one- 
tenth  grain)  of  calomel  for  four  or  five  doses,  with  intervals  of  one-half 
hour,  or  a  4  to  16  c.c.  (1  to  4  drachms)  of  milk  of  magnesia.  If  the  food  has 
been  human  milk  an  analysis  of  the  milk  should  be  made  at  once,  and  the 
milk  should  be  modified  according  to  the  rules  which  have  already  been 
given.  If  the  infant  is  being  fed  on  an  improperly  modified  milk,  or  if  im- 
proper food  of  any  kind  has  been  given  to  it,  a  recurrence  of  the  attacks 
can  easily  be  obviated  by  a  modification  of  the  elements  of  the  food  which 
seem  to  have  produced  the  disturbance.  Thus,  in  a  number  of  cases  we 
have  found  that  whenever  the  infant's  food  was  modified  so  as  to  raise  the 
percentage  of  the  sugar  above  5,  acute  indigestion  followed.  In  like  man- 
ner in  certain  cases  the  percentage  of  the  fat  had  to  be  reduced  to  3,  or 
perhaps  2,  and  the  proteids  even  as  low  as  0.25,  for  a  number  of  weeks 
until  the  digestive  function  of  the  stomach  became  normal.  As  relapses 
are  common  when  food  in  any  form  is  given  too  soon  after  the  attack, 
nothing  should  be  given  excepting  boiled  water  with  a  few  drops  of  brandy 
for  six  or  eight  hours. 

In  older  children  the  symptoms  are  similar  to  those  which  have  just 
been  described,  and  the  diagnosis  and  treatment  the  same  as  in  the  infant. 
After  allowing  the  stomach  to  rest,  a  recurrence  of  the  attack  is  best  pre- 
vented by  at  once  placing  the  child  for  several  days  on  an  exclusive  diet  of 
a  milk  modified  in  such  a  way  as  to  contain  a  percentage  of  from  2  to  3  of 
fat,  5  to  6  of  sugar,  0.25  to  1.00  of  proteids,  and  10  of  lime-water. 

CHRONIC  GASTRIC  INDIGESTION  (Chronic  Dyspepsia). 

This  is  one  of  the  most  common  and  most  important  diseases  of  the 
gastro-enteric  tract.  It  is  mainly  a  disease  of  the  first  year  of  life  and  is 
most  common  in  those  infants  who  are  fed  on  some  other  food  than 
human  breast-milk.  It  may  be  of  a  chronic  type  from  the  beginning  or 
may  develop  as  the  result  of  repeated  acute  attacks. 

Etiology. — The  cause  is  almost  invariably  a  lack  of  correspondence 
between  the  quantity  or  quality  of  the  food  and  the  individual  digestive 
capacity,  which  leads  to  impairment  of  function. 

Symptoms. — In  infants  the  symptoms  of  chronic  indigestion  are  much 
less  severe  than  those  of  the  acute  form.  The  infant  is  apt  to  vomit  after 
taking  its  food,  to  be  restless,  fretful,  and  either  to  lose  in  weight  or  not  to 
gain.  Its  sleep  will  be  very  much  disturbed,  apparently  by  pain  from  flatus. 
In  chronic  indigestion  the  bowels  are  apt  to  be  constipated,  but  this  is 
not  always  the  case.  The  chronic  indigestion  of  older  children  presents 
a  somewhat  different  aspect.  The  temperature  is  at  times  somewhat 
heightened.     The  tongue  is  apt  to  be  coated,  and  the  breath  to  have  a  sour 


784  PEDIATRICS. 

or  unpleasant  odor.  These  children  do  not  vomit  so  frequently  as  do  infants. 
They  lose  in  weight,  become  fretful,  and  get  tired  easily.  A  mild  form  of 
intestinal  indigestion  is  likely  to  be  associated  with  the  gastric  disturbance. 

Treatment. — We  have  seldom  found  the  use  of  any  especial  drug  to  be 
of  much  benefit  in  these  cases  of  chronic  indigestion.  In  quite  a  number 
of  cases  of  both  acute  and  chronic  indigestion,  before  any  food  is  intro- 
duced into  the  stomach  it  is  often  wise  first  to  wash  out  the  stomach 
thoroughly  (lavage).  This  procedure  is  especially  mdicated  if  the  indi- 
gestion has  produced  continuous  vomiting. 

The  technique  of  washing  out  the  stomach  is  very  simple.  A  soft 
rubber  catheter  with  a  double  eye,  No.  21  French  scale,  for  infants  under 
six  months,  and  No.  25  for  older  children,  is  attached  by  means  of  a  piece 
of  glass  tubmg  7.5  cm.  (3  inches)  long  to  another  rubber  tube  which  is 
50.5  cm.  (20  inches)  long  attached  to  a  funnel,  preferably  of  hard  rubber, 
and  capable  of  holding  from  90  to  120  c.c.  (3  or  4  ounces).  The  infant 
is  seated  upright  in  the  nurse's  lap,  with  its  head  inclined  forward  and 
resting  on  the  nurse's  arm.  Its  arms  are  controlled  by  a  towel  pumed 
around  them.  The  catheter,  having  been  wet  with  warm  water,  is  easily 
passed  over  the  base  of  the  tongue  into  the  stomach.  As  there  is  often 
consideraJ^le  gas  in  the  stomach,  the  funnel  should  be  raised  as  high  as 
possible  above  the  infant's  head,  in  order  that  the  gas  may  pass  out  from 
the  stomach.  From  90  to  120  c.c.  (3  or  4  ounces)  of  sterilized  water 
should  be  poured  into  the  stomach  by  means  of  the  funnel.  The  funnel 
is  then  depressed  below  the  level  of  the  stomach,  and  the  gastric  contents 
will  in  this  way  be  siphoned  out.  As  the  curds  are  often  too  large  to 
pass  through  the  eye  of  the  catheter,  a  number  of  washings  will  often  be 
necessary  to  break  them  up.  By  washmg  out  the  stomach  not  only  are 
the  irritating  substances  which  are  producing  the  indigestion  removed,  and 
the  mucous  lining  of  the  stomach  left  free  to  recover  its  normal  condition, 
but  it  is  also  possible  to  have  a  chemical  examination  of  the  contents 
made.  Clinically,  however,  the  latter  is  not  necessary,  although  it  is  of 
-great  interest  physiologicahy.  No  food  should  be  introduced  into  the 
stomach  for  at  least  tw^o  hours  after  the  washing.  The  washing  of  the 
stomach  is  almost  entirely  free  from  danger,  except  in  very  weak  infants, 
and,  in  addition  to  being  an  important  part  of  the  treatment  of  indigestion, 
is  often  of  great  use  when  poisonous  substances  have  been  sAvallowed. 

This  method  of  treating  disturbances  of  the  stomach  is  more  valuable 
in  young  infants  than  in  older  children,  because  the  latter  resist  so  vigor- 
ously that  the  remedy  is  often  of  more  harm  than  good.  The  tube  can, 
however,  usually,  even  in  older  children,  be  introduced  by  aid  of  the 
ordinary  gag  which  is  used  for  intubation.  Two  assistants  are  usually 
necessary  in  introducing  the  tube  in  older  children,  while  in  infants  one 
assistant  is  sufficient.  In  some  cases  it  is  found  necessary  to  introduce 
the  tube  through  the  nose.  The  tube  should  be  passed  into  the  throat 
rapidly,   since   the   gagging  and   vomiting   occur   chiefly  when   the  tube 


DISEASES    OF   THE    STOMACH.  785 

touches  the  pharynx.     There  is  iisuany  an  escape  of  gas  or  gastric  con- 
tents as  soon  as  the  tube  enters  the  stomach. 

When  the  mflow  of  water  through  the  tube  is  sliown  to  be  too  rapid, 
by  the  fact  that  the  infant  holds  its  breath  too  long,  or  by  its  crying,  vom- 
iting, or  coughing  continuously,  the  flow  should  be  stopped  for  a  short 
time.  Care  must  also  be  taken  not  to  mtroduce  the  catheter  too  far  into 
the  stomach,  as  it  may  bend  on  itself  and  interfere  "\^^th  the  flow  of  the 
returning  water  and  gastric  contents.  If  the  gastric  contents  are  expelled 
along  the  side  of  the  tube  rather  than  through  it,  the  tube  should  be  A\ath- 
d^a^vn  until  the  vomiting  has  ceased.  There  seems  to  be  no  danger  of 
passing  the  tube  into  the  larynx,  or  of  perforating  the  stomach  ^dth  it. 

Lavage  is  contra-indicated  when  there  is  cardiac  disease  or  any  severe 
pulmonary  disturbance,  and  when  the  introduction  of  the  catheter  con- 
tinues to  excite  vomiting  it  should  be  used  with  extreme  caution.  The 
fact  that  the  infant  is  in  a  feeble  condition  is  not  a  contra-indication  to  this 
treatment. 

In  connection  with  lavage  it  is  well  to  speak  of  forced  feeding  (gavage) 
in  the  treatment  of  mfants  and  young  children.  In  cases  of  acute  and 
chronic  indigestion,  and  also  when  a  catarrhal  condition  of  the  stomach 
is  present,  the  infants  at  times  refuse  to  take  any  food  whatever.  This 
does  not  occur  merely  when  the  disturbance  is  in  the  stomach  ;  we  have 
frequently  met  mth  it  in  severe  cases  of  all  kinds  of  disease.  In  a  num- 
ber of  instances,  when  the  mfants  would  probably  have  died  of  starva- 
tion had  not  gavage  been  employed,  this  means  of  pro^dcling  for  their 
nourishment  has  been  verj^  successful.  Forced  feechng  may  sometimes 
have  to  be  employed  for  a  number  of  days,  and  even  weeks,  before  the 
child  Viill  of  itself  swallow  again. 

The  technique  of  gavage  is  similar  to  that  of  laA'age.  The  same  appa- 
ratus is  employed,  and  the  child  should  be  placed  flat  on  its  back  in  bed 
or  held  half  reclinmg.  The  head  is  held  by  an  assistant.  The  catheter 
should  be  passed  mto  the  stomach  rapidly,  the  funnel  raised  up  in  the  air 
for  a  few  muiutes  in  order  that  the  gas  may  escape,  and  the  amount  of 
food  adapted  to  the  age  of  the  child  should  then  be  poured  into  the  funnel. 
As  the  last  of  the  food  disappears  from  the  funnel,  the  catheter  is  pinched 
tightly  and  quickly  ^^Ithdrawn.  This  precaution  is  important,  in  order 
that  the  pharynx  shall  not  be  frritated  either  by  the  slow  withdrawal  of 
the  catheter  or  by  the  trickling  of  the  remains  of  the  fluid,  as  vomiting 
may  in  this  way  be  excited. 

One  of  the  advantages  which  has  resulted  from  the  use  of  the  stomach- 
tube  is  the  knowledge  we  have  acqufred  of  the  time  wliich  the  food  re- 
mains m  the  stomach  at  chfferent  ages.  Thus,  it  has  been  found  that  during 
the  early  weeks  of  life  the  stomach  is  nearly  emptied  in  an  hour,  wliile 
in  older  infants  two  hours  are  reqmred  for  the  same  process.  This  knowl- 
edge is  especially  valuable  when  we  are  regulating  the  mtervals  of  feeding 
in  premature  infants,  and  m  infants  during  the  first  six  months  of  life. 

50 


786  PEDIATRICS. 

When  other  means  can  be  employed,  they  are  preferable  to  the 
stomach-tube,  but  m  many  instances  when  infants  or  children  refuse  to 
take  their  food  the  simplest  Avay  of  forcing  it  upon  them  is  to  pinion  the 
arms  with  a  towel  and  have  the  nurse  hold  the  child  half  reclining  in 
her  lap.  Sometimes  an  assistant  is  needed  to  hold  the  head,  but  this  is 
often  unnecessary.  Simply  pressing  the  child's  nostrils  with  the  thumb  and 
finger  will  cause  it  to  open  its  mouth,  and  the  food  can  then  be  poured  in 
with  a  spoon,  or  introduced  by  the  Breck  feeder  or  liv  means  of  a  dropper 
with  a  large  end. 

A  child,  two  and  one-half  years  old,  would  not  take  any  food  without  ])eing  forced 
to  do  so.  Although  this  child  was  very  ill  with  pneumonia,  involving  both  lungs,  it 
was  fed  every  two  or  three  hours,  night  and  day,  by  this  method.  After  the  first  two 
or  three  feedings  it  did  not  resist,  and  the  nose  did  not  have  to  be  pinched,  all  that 
was  necessary  being  to  threaten  to  do  so.  120  c.c.  (4  ounces)  of  milk  were,  after  a 
little  practice,  introduced  by  means  of  the  dropper  into  the  child's  stomach  in  five  or 
six  minutes. 

We  have  found  that  the  most  speedy  cure  of  chronic  indigestion  is  to 
give  the  child  a  carefully  modified  alkaline  milk.  In  most  cases  it  will  be 
necessary  to  reduce  the  fat  or  sugar,  in  others  the  proteids,  but  in  every 
case,  as  soon  as  it  is  determined  which  of  these  elements  in  full  strength 
does  not  suit  the  individual  digestion,  an  improvement  in  the  symptoms 
will  soon  follow  the  reduction  of  the  percentage  of  that  element.  In  some 
cases  peptonization  of  the  milk  after  modification  is  found  valuable,  or  the 
peptonizing  powder  may  be  given  with  the  food,  which,  if  made  alkaline 
with  fifteen  or  twenty  per  cent,  of  lime-water,  will  in  large  part  pass 
quickly  into  the  duodenum,  and  thus  relieve  the  stomach  of  some  of  its 
function  of  digestion.  After  the  indigestion  has  been  relieved  by  this 
means,  other  articles  of  diet  adapted  to  the  age  of  the  child  can  gradually 
be  added.     (See  article  on  Feeding,  page  180.) 

In  addition  to  the  direct  treatment  of  the  stomach,  the  intestinal  dis- 
turbance which  almost  always  accompanies  the  gastric  indigestion  should 
~be  relieved  by  occasionally  giving  a  dose  of  some  mild  laxative,  preferably 
one  of  the  salts  of  magnesia,  such  as  the  citrate.  This  latter  treatment  is 
indicated  not  only  for  children,  but  for  young  infants,  because,  when  there 
is  gastric  indigestion,  the  undigested  food  which  passes  into  the  duodenum 
is  a  prolific  source  of  intestinal  disturbance.  This  by  adding  to  the  dis- 
comfort of  the  child,  weakens  it,  and  tends  to  prolong  the  gastric  indiges- 
tion. In  the  more  intractable  cases,  small  doses  of  bismuth,  soda,  or 
dilute  hydrochloric  acid  may  be  useful.  Bismuth  is  indicated  for  allaying 
irritation  and  counteracting  fermentation.  Soda  and  hydrochloric  acid 
have  to  be  used  somewhat  empirically,  as  we  know  so  little  about  the 
chemical  conditions  present.  After  the  more  prominent  gastric  symptoms 
have  disappeared,  considerable  benefit  can  be  obtained  by  using  small 
doses  of  the  tincture  of  nux  vomica  for  several  weeks. 


DISEASES   OF   THE   STOMACH.  787 

TBAUMATIO. 
Rare  cases  occur  of  traumatic  injury  of  the  stomach.     Among  the 
causes  are  foreign  bodies  and  corrosive  substances.     Various  anatomical 
lesions  are  found  in  such  cases,  all  of  which  are  included  under  the  term 
gastritis.     Of  these  the  most  important  is  corrosive  gastritis. 

CORROSIVE  GASTRITIS. 

Corrosive  lesions  of  the  mucous  membrane  of  the  stomach  are  at 
times  produced  by  swallowing  irritants,  such  as  arsenic,  carbolic  acid,  and 
caustic  fluids.  In  these  cases  the  lesions  are  usually  found  on  the  summits 
of  the  rugae. 

Treatment. — The  treatment  is  to  wash  out  the  stomach  with  large  quan- 
tities of  water,  to  administer  the  proper  antidote,  and  to  give  a  licjuid  diet 
so  modified  as  to  be  as  little  irritating  as  possible  to  the  injured  mucous 
membrane. 

III.  Infectious. — In  comparison  with  the  intestine,  infections  of  the 
stomach  are  rare.  The  chief  infections  of  the  stomach  which  are  of  in- 
terest clinically  are  represented  anatomically  by  some  form  of  gastritis. 
Gastritis  may  be  of  the  catarrhal  form  or  it  may  be  pseudomembranous. 
Catarrhal  gastritis  may  be  acute  or  chronic  ;  it  is  usually  associated  with 
enteric  disturbance. 

INFECTIOUS  GASTRmS. 

Gastric  infection  is  rare  and  comparatively  is  very  much  more  rare 
than  intestinal  infection. 

Etiology. — Improper  feeding,  with  its  resulting  gastric  indigestion,  is 
the  predisposing  cause,  infection  probably  resulting  from  increased  vulner- 
ability of  the  gastric  mucous  membrane.  The  nature  of  the  infection  is 
variable,  but,  with  the  exception  of  its  occurrence  in  connection  with  such 
diseases  as  tuberculosis  and  diphtheria,  the  streptococcus  is  probably  the 
most  frequent  organism  present. 

Pathological  Anatomy. — The  lesions  found  in  infectious  gastritis  may 
be  divided  into  (a)  catarrhal,  (6)  ulcerative  and  (c)  pseudomembranous 
gastritis. 

Catarrhal  gastritis  shows  hyperaemia  of  the  mucous  membrane, 
hypersecretion  of  mucus,  small  punctate  hemorrhages  and  slight  thick- 
ening of  the  mucous  coat. 

The  undigested  food  remains  longer  than  normal  in  the  stomach  and  is 
mixed  with  an  excess  of  mucus. 

Microscopically  the  changes  are  confined  mainly  to  the  mucosa  and 
consist  of  degeneration,  infiltration  in  places  with  round  cells  and  at 
times  loss  of  surface  epithelium.  Rarely,  in  chronic  cases,  there  is  more 
marked  infiltration  and  an  increase  of  the  connective  tissue. 

Ulcerative  gastritis  is  extremely  rare.  The  ulcers  are  usually  follicular, 
numerous,  vary  from  mere  dots  to  \  inch  in  diameter,  and  usually  involve 
only  the  mucosa. 


788 


PEDIATRICS. 


Ffieuclomembranous  gastritis  is  still  more  rare.  In  this  condition  there 
is  a  grayish  or  greenish  adherent  false  membrane,  consisting  microscopi- 
cally of  fibrin,  granular  matter,  epithelial  cells,  and  detritus. 

There  is  round-celled  infiltration  of  the  mucosa,  submucosa,  and  some- 
times even  of  the  muscular  coat.  This  form  is  usually  accompanied  by 
ulcerative  gastritis. 

Fig.  162  represents  follicular  ulceration  of  the  stomach  found  in  a  girl 

one  year  old. 

Fig.  162. 


Follicular  ulceration  of  stxjmacli.    Female,  1  year  old. 


Symptoms. — Of  the  different  forms  of  gastritis  the  catarrhal  is  very 
much  the  most  common.  There  are  no  peculiar  symptoms  by  which  the 
ulcerative  and  pseudomembranous  varieties  can  be  recognized  with  any 
certainty. 

Acute  Catarrhal  Gast^Htis. — The  symptoms  of  acute  catarrhal  gastritis 
resemble  at  the  onset  those  of  acute  gastric  indigestion.  There  is  nausea, 
vomiting,  thirst,  loss  of  appetite,  and  usually  some  prostration.  Fever  is 
always  present,  whereas  it  is  usually  absent  in  gastric  indigestion.  Abdom- 
inal tenderness  is  often  present.     The  continuance  of  the  symptoms,  par- 


DISEASES   OF   THE   STOMACH.  789 

ticularly  of  the  fever,  vomiting,  pain,  and  tenderness,  is  tlie  basis  for  the 
diagnosis  of  acute  catarrhal  gastritis.  The  temperature  is  usually  mod- 
erate, 37.7°-38.8°  C.  (100°-102°  F.)  after  the  onset. 

There  may  be  constitutional  symptoms  at  the  onset.  There  is  usually 
frothy  mucus  in  the  vomitus,  which  is  sometimes  streaked  with  blood. 

Prognosis. — Attacks  of  acute  catarrhal  gastritis,  even  when  properly 
treated,  are  apt  to  last  for  from  three  to  seven  days.  When  not  properly 
treated  they  may  be  prolonged  or  chronic  gastritis  may  develop.  When 
properly  treated  the  prognosis  is  good. 

Treatment. — The  treatment  of  cases  of  acute  catarrhal  gastritis  is  the 
same  as  that  described  in  speaking  of  indigestion.  Food  should  be  with- 
held from  the  stomach  for  many  hours,  for  it  remains  so  long  in  the 
stomach  that  a  fresh  supply  at  short  intervals  will  act  as  an  additional 
source  of  irritation.  In  those  cases  which  do  not  respond  readily  to  long 
intervals  of  rest  and  to  feeding  with  small  quantities  of  a  modified  alkaline 
milk,  lavage  will  prove  of  value.  Much  judgment  should  be  used  as  to 
the  time  when  the  food  is  to  be  increased  in  strength,  for  unless  great 
precautions  are  taken  relapses  will  frec|uently  occur,  and  as  a  result  the 
disease  may  finally  become  chronic.  After  convalescence  has  been  estab- 
lished the  child  will  begin  to  gain  in  weight.  Some  simple  tonic,  such  as 
nux  vomica,  is  usually  indicated  for  a  week  or  ten  days  until  the  child  has 
recovered  its  strength.  During  the  beginning  of  the  attack,  when  food  is 
being  mthheld,  if  the  cliild  is  made  yerj  restless  by  extreme  thirst,  tea- 
spoonful  doses  of  iced  soda-water  can  be  given,  but  with  caution  and  as 
seldom  as  possible.  After  the  irritation  has  been  somewhat  allayed, 
it  is  found  valuable  in  certain  cases  to  give  dilute  solutions  of  brandy, 
barley  water,  or  white  of  egg  in  the  form  of  albumin  water  before  begin- 
ning with  the  treatment  just  spoken  of.  Albumin  water  is  best  made  by 
dissohing  the  white  of  an  egg  20  to  30  c.c.  (f  to  1  ounce)  in  water  120 
c.c.  (4  ounces),  and  heating  to  40°  C.  (104°  F.).  In  this  way  the  albu- 
min is  held  in  solution,  and  the  albumin  water  can  be  put  on  ice  until 
needed  for  use.  In  especially  intractable  cases  nothing  should  be  put  in 
the  stomach  for  some  time,  nutriment  being  given  in  the  form  of  pep- 
tonized milk  with  enemata.  The  child  should  be  placed  in  a  darkened 
room  and  soothing  applications  applied  to  the  al3domen.  If  there  is  much 
exhaustion,  stimulants  are  indicated. 

Chronic  Catarrhal  Gastritis. — Chronic  catarrhal  gastritis  is  usually  the 
result  of  prolonged  or  repeated  attacks  of  the  acute  form. 

Symptoms. — The  symptoms  of  chronic  catarrhal  gastritis  resemble  in  a 
general  way  those  of  chronic  gastric  indigestion.  There  is  usually  little  or 
no  fever.  There  may  be  some  abdominal  tenderness.  The  only  charac- 
teristic symptom  is  the  prolonged  presence  of  an  excess  of  mucus  in  the 
vomitus,  and  evidence  of  malnutrition. 

Prognosis. — Chronic  catarrhal  gastritis  is  apt  to  be  somewhat  intrac- 
table, but  recovers  under  appropriate  treatment. 


790  PEDIATRICS. 

Treatment. — It  is  often  necessary  in  these  cases  to  precede  the  treat- 
merit  by  carefully  washhig  out  the  stomach.  We  must  remember,  how- 
ever, that  a  considerable  c]uantity  of  mucus  may  be  in  the  stomach,  which 
cannot  be  removed  by  washing,  so  that  if  the  symptoms  continue  after  one 
or  two  washings,  even  though  no  mucus  is  returned  by  the  tube,  we 
should  repeat  this  treatment  from  time  to  time.  The  diet  should  be  an 
alkaline  modified  milk,  with  a  low  percentage  of  proteids,  if  necessary 
peptonized,  and  a  moderate  percentage  of  fat  and  sugar.  The  percentages 
of  the  different  elements  should  be  increased  as  improvement  in  the  gastric 
symptoms  takes  place,  and  later  broths  and  undiluted  milk  can  be  tried. 
Symptomatically  in  certain  cases  pepsin,  dilute  hydrochloric  acid,  and  bis- 
muth are  occasionally  indicated.  A  valuable  tonic  in  the  after-treatment 
of  these  cases  is  nux  vomica. 

The  treatment  already  described  on  page  784  for  chronic  gastric  in'di- 
gestion  is  indicated  for  chronic  catarrhal  gastritis. 

DISEASES  OF  THE  INTESTINE. 

Diseases  of  the  intestine  may  arise  from  developmental,  non-infectious, 
and  infectious  causes. 

I.  Developmental. — Certain  malpositions  and  malformations  of  the 
intestines  occur  as  a  result  of  abnormal  development. 

Malpositions  are  met  with  in  infants  when  there  is  a  transposition  of 
the  abdominal  organs,  or  when  portions  of  the  intestines  are  found  to  be 
outside  of  the  abdominal  cavity. 

Malformations  have  been  described  under  diseases  of  the  new-born. 
We  have  seen  two  cases  of  developmental  disease,  in  which  the  symptoms 
were  only  those  of  chronic  gastric  and  intestinal  indigestion,  in  whom 
congenital  malformations  of  the  intestines  were  proved  at  autopsy  to  be 
the  direct  cause.  In  one  of  the  cases  the  intestine  from  the  lower  end 
of  the  sigmoid  to  the  splenic  flexure  of  the  descending  colon  was  barely 
large  enough  to  admit  a  No.  12  soft-rubber  English  catheter.  In  the  other 
-case  there  were  two  strictures,  one  at  the  junction  of  the  sigmoid  flexure 
and  rectum,  and  the  other  where  the  sigmoid  joins  the  descending  colon. 
The  sigmoid  itself  and  colon  were  dilated  to  three  or  four  times  their 
normal  size.  Undoubtedly  many  cases  of  chronic  gastric  and  intestinal 
indigestion,  which  persist  in  spite  of  most  careful  feeding,  are  due  to  mal- 
formations and  faulty  development  which  are  impossDole  to  detect  clinically. 

II.  Non-infectious. — The  non-infectious  diseases  of  the  intestine  may 
be  divided  into  Mechanical,  New  Growths,  and  Functional. 

MEOBLANIOAIi. 
The  mechanical  diseases  of  the  intestine  are  quite  numerous,  but, 
with  few  exceptions,  are  not  of  especial  importance  medically,  and  belong 
rather  to  the  province  of  surgery.     They  should,  however,  be  referred  to 
for  the  purpose  of  differential  diagnosis. 


DISEASES   OF  THE   INTESTINE. 


791 


They  are  represented  by  dilatation  of  the  colon,  volvulus,  intussus- 
ception, hernia,  fissure,  prolapse,  and  hemorrhoids.     (See  Developmental.) 

DILATATION   OF  THE  COLON. 

]n  comparison  with  dilatation  of  the  stomach,  dilatation  of  the  colon 
is  very  rare  except  as  a  tem^porary  condition.  It  is  liable  to  occur  at  any 
time  from  an  over-production  of  gas.     If  permanent,  it  is  usually  congeni- 

Fia.  163. 


Dilatation  of  colon.    Male,  12  years  old. 


tal,  or  it  may  be  secondary  to  some  congenital  malformation  such  as 
stricture  of  the  intestine.  The  chief  symptoms  are  obstinate  constipa- 
tion and  distention  of  the  alDdomen.  The  distention,  which  may  be 
extreme,  often  disappears  temporarily  after  the  evacuation  of  the  faecal 
and  gaseous  matter.  Emaciation  is  usually  prominent.  Diarrhoea  may 
alternate  with  periods  of  prolonged  constipation.  The  condition  is 
usually  fatal,  but  adult  life  may  be  reached.  The  treatment  is  essentially 
surofical. 


792  PEDIATRICS. 

The  following  case  illustrates  a  dilatation  of  the  colon,  which  was  seemingly 
caused  hy  a  congenital  stricture,  and  in  which  an  artificial  anus  was  made  by  Halsted. 
The  child  recovered  from  the  operation,  but  later,  owing  to  still  further  obstruction, 
he  had  to  he  operated  on  again  and  died.  In  this  case  the  extreme  distention  of  the 
abdomen,  which  was  tympanitic  through  its  whole  extent,  the  evident  obstruction  to 
the  fajcal  discharges,  and  the  absence  of  symptoms  pointing  towards  gastric  disease, 
would  suggest  a  dilatation  of  some  part  of  the  intestine,  presumably  of  the  colon. 

VOLVULUS. 
By  volvulus  is  meant  a  twisting  or  bending  of  the  intestine.  This 
condition  is  more  apt  to  occur  in  early  life  than  later,  possibly  because  of 
the  greater  proportionate  length  of  the  mesentery  at  this  time,  which 
allows  the  intestine  greater  latitude  of  motion.  It  occurs  either  by  itself 
or  in  connection  with  intussusception,  from  which  it  is  to  be  differentiated 
by  the  absence  of  blood  and  mucus  in  the  discharges. 

INTUSSUSOEPTION. 

Intussusception  or  invagination  is  a  condition  in  which  a  part  of  the 
intestine  has  passed  down  into  another  part.  Under  these  circumstances 
there  is  an  outer  layer  of  intestine  within  which  is  the  part  of  the  intestine 
forming  the  invagination.  Only  a  small  portion  of  the  intestine  may  be 
invaginated,  or  it  may  extend  from  the  ileo-ca^cal  valve  to  the  rectum. 
Small  invaginations  are  frequently  found  at  the  post-mortem  examinations 
of  infants  and  young  children.  These  probably  take  place  during  the 
death-struggle,  as  no  pathological  condition  is  found  in  connection  with 
them.  This  form  is  usually  multiple  and  in  the  small  intestine.  The 
form  of  intussusception  which  occurs  during  life  is  very  rare  under  three 
months,  and  is  most  common  from  the  third  to  the  sixth  month.  At  this 
age  the  large  intestine  is  shorter  in  relation  to  the  small  intestine  than  in 
the  adult,  while  the  mesentery  is  relatively  wider,  and  thus  allows  much 
greater  latitude  for  misplacement,  especially  of  the  caecum  and  colon. 
The  etiology  of  intussusception  is  obscure,  but  it  is  probably  directly  due 
to  increased  local  peristalsis. 

^  Pathological  Anatomy. — The  pathological  anatomy  depends  upon  the 
tightness  of  the  constriction  and  the  length  of  time  from  the  beginning  of 
the  obstruction.  In  some  cases  the  incarcerated  portion  of  the  intestine  is 
so  little  constricted  that  the  bowel  remains  pervious.  In  other  cases  the 
constriction  is  so  great  that  the  tension  of  the  iatestinal  capillaries  quickly 
becomes  so  extreme  that  hemorrhage  occurs,  and  inflammation,  with  result- 
ing adhesions,  is  apt  to  follow  rapidly.  The  intestine  may  not  only  be 
invaginated,  but  may  be  bent  on  itself,  an  important  point  to  remember  in 
regard  to  treatment. 

Symptoms. — The  symptoms  of  intussusception  are  usually  more  acute 
in  infants  than  in  older  children.  In  infants  they  are  often  at  first  rather 
obscure.  Paroxysmal  pain  and  discharges  of  blood  from  the  rcstum 
occur.     Later  the  blood  is  mixed  with  mucus  and  looks  like  currant  jelly. 


DISEASES  OF   THE   INTESTINE.  793 

Tliere  is  usually  vomiting,  which  may  he  stercoraceous.  The  mind  is 
clear,  and  in  young  infants  the  face  is  often  tranquil  between  the  parox- 
ysms of  pain,  so  that  on  looking  at  the  infant  it  would  scarcely  be  sup- 
posed that  a  serious  condition  was  present.  Later,  however,  the  face 
grows  haggard  and  the  eyes  become  sunken.  During  the  first  twenty-four 
to  forty-eight  hours,  and  even  longer,  the  infants  will  often  take  their  food 
quite  readily.  Tenesmus  is  at  times  present.  There  may  be  fever,  espe- 
cially when  inflammation  has  occurred.  The  pulse  is  usually  quickened. 
These  symptoms  all  varj^,  and  depend  on  the  amount  of  the  invagination. 
In  some  cases  these  are  the  only  signs  which  indicate  that  there  is  abdomi- 
nal disturbance.  In  many  instances,  however,  either  at  once  or  witliui  a 
few  hours,  a  tumor  can  be  felt  in  the  abdomen. 

Diagnosis. — ^The  chief  points  in  the  diagnosis  of  intussusception  are 
the  occurrence  of  discharges  of  blood,  vomiting,  abdominal  pain,  and  the 
detection  of  an  abdominal  tumor,  usually  on  the  left  side  of  the  abdomen. 
In  these  cases  a  careful  rectal  examination  should  always  be  made,  for  a 
tumor  can  often  be  found  in  this  way  when  an  external  examination  has 
failed  to  detect  it. 

Prognosis. — ^AVithout  treatment  the  prognosis  is  unfavorable,  though 
there  are  a  certain  number  of  recoveries  by  spontaneous  reduction,  or 
rarely  by  sloughing  of  the  invaginated  portion  of  the  intestine,  vrhich  is 
then  passed  by  the  rectum.  If  death  takes  place,  it  usually  occurs  about 
the  third  or  fourth  day,  or  at  any  rate  within  a  ^^"eek,  after  the  incarcera- 
tion is  complete.  When  the  incarceration  is  not  complete  the  infant  may 
live  for  many  weeks,  and  in  older  children  in  rare  instances  the  disease 
may  become  chronic. 

Treatment. — The  treatment  of  intussusception,  when  the  cUagnosis  has 
been  definitely  made,  should  be  immediate,  as  in  no  other  disease  does  a 
delay  result  m  more  serious  consequences.  Food  and  cathartics  or  laxa- 
tives are  contra-indicated.  If  the  infant  shows  signs  of  collapse,  small 
quantities  of  brandy-and-water  should  be  given.  In  the  early  hours  of 
the  attack  an  attempt  should  be  made  to  reduce  the  intussusception  by 
hydrostatic  pressure.  This  can  be  easily  done  by  having  the  mfanfs  but- 
tock's somewhat  raised  and  introducing  water  under  a  pressure  of  about 
one  metre  (3|-  feet)  by  means  of  a  fountain  syringe.  The  water  should  be 
lukewarm,  and  should  have  dissolved  in  it-salt  in  the  proportion  of  one 
teaspoonful  to  a  quart.  The  abdomen  should  be  gently  rubbed  at  the 
same  time.  In  some  cases  this  procedure  results  in  a  reduction  of  the 
intussusception,  but  when  this  is  not  accomplished  an  anaesthetic  should 
be  given  and  the  attempt  repeated. 

Even  when  inflammation  has  not  begun  and  adhesions  have  not 
formed,  the  pressure  of  the  column  of  water  may  fail  to  reduce  the  intus- 
susception, because  the  invaginated  portion  may  be  bent  on  itself,  so  that 
the  hydrostatic  pressure  increases  the  obstruction  rather  than  relieves  it. 
^Vhen  adhesions  have  taken  place  and  when  there  is  gTeat  congestion,  as 


794  PEDIATRICS. 

sometimes  occurs  during  the  first  twenty-four  hours  of  the  attack,  hydro- 
static pressure  is  usually  unsuccessful  and  may  be  dangerous.  If  this 
method  has  failed,  the  infant  should  be  placed  at  once  in  the  hands  of  a 
surgeon,  as  under  these  circumstances  an  early  laparotomy  Avill  give  the 
most  favorable  results. 

The  following  case  of  intussusception  illustrates  the  importance  of  not 
delaying  operation  : 

A  male  infant,  six  months  old,  nursed  by  its  mother,  and  previously  perfectly 
healthy,  after  a  slight  loss  of  appetite  for  several  days  began  to  have  al)dominal  pain  in 
the  morning,  and  in  the  middle  of  the  day  had  a  discharge  of  blood  from  the  rectum 
unmixed  with  ftecal  matter  or  mucus.  The  bowels  had  been  thoroughly  moved  on  the 
previous  day,  and  there  had  been  no  tendency  to  constipation.  During  the  afternoon 
there  were  five  or  six  discharges  of  blood.  In  the  evening  the  infant  looked  well  and 
did  not  show  any  signs  of  discomfort  except  occasional  slight  attacks  of  abdominal  pain 
and  an  indisposition  to  nurse.  The  rectal  temperature  was  39°  C.  (102.2°  F.).  An 
examination  of  the  abdomen  externally  and  by  the  rectum  revealed  nothing  abnormal. 
The  infant  had  a  restless  night,  vomited  several  times  after  nursing,  and  had  six  dis- 
charges of  blood.  The  temperature  was  38.3°  C.  (101°  F.),  the  pulse  135,  strong  and 
regular,  and  the  general  appearance  good.  The  abdomen  was  soft  and  not  tender  on 
pressure,  but  towards  the  umbihcus.  under  the  left  costal  border,  a  rather  ill-defined 
cylindrical  tumor  could  be  detected. 

Hydrostatic  pressure  was  employed  to  reduce  the  intussusception,  but  failed.  The 
surgeon  who  saw  the  infant  on  the  second  day  decided  to  wait  twenty-four  hours  before 
performing  laparotomy.     On  the  following  day  the  infant  died  suddenly. 

At  the  post-mortem  examination  nothing  abnormal  was  found  except  an  ileo-csecal 
intussusception.  An  examination  of  the  invagination  showed  that  the  retained  caecum 
was  so  tmsted  that  the  lower  opening  was  directed  to  one  side  of  the  axis  of  the  intestine, 
and  the  hydrostatic  pressure  from  below  must  have  simply  packed  the  sac  tighter  and 
rendered  reposition  more  difficult.  The  invagination  involved  20  cm.  (8  inches)  of  the 
inlestine.  The  serous  surfaces  were  firmly  adherent  through  their  whole  extent,  and 
considerable  force  was  required  to  reduce  the  invagination  wdthout  tearing  it.  The  re- 
duction, however,  was  successfully  accomplished,  the  adhesions  gi^*ing  way  and  the 
intestine  being  left  uninjured  and  apparently  healthy.  This  case  illustrates  how  neces- 
sary it  is  to  employ  the  most  skilled  surgical  aid  in  these  cases. 

HERNIA. 

Hernia  is  essentially  a  surgical  disease,  and  has  been  described  in  the 
division  on  diseases  of  the  new-born.     Page  290, 

FISSURES. 

There  are  a  number  of  lesions  which  occur  about  the  anus  in  infants 
and  young  children  which,  although  somewhat  rare,  should  be  recognized 
for  purposes  of  cUfferential  diagnosis.  They  are,  however,  so  purely  sur- 
gical in  their  treatment  that  they  need  only  be  mentioned  here. 

One  of  these  conditions  is  that  of  fissure,  which  occurs  either  at  the 
anus  or  more  commonly  a  little  distance  from  the  orifice.  Pruritus  and 
reflex  urinary  symptoms  are  common.  Defecation  is  often  painful,  and 
constipation  of  the  spasmodic  type  may  thus  result.  xA.  general  nervous 
irritation  at  times  results  from  fissures  of  the  anus  which  may  seriously 


DISEASES   OF   THE   INTESTINE.  795 

interfere  with  the  nutrition  of  the  child.  The  treatment  is  cleanliness 
and  the  application  of  boracic  acid  ointment  or  the  stick  of  nitrate  of  sil- 
ver every  two  or  three  days.  If  these  measures  fail,  stretching  of  the 
sphincter  under  anaesthesia  usually  cures  the  disease. 

PROLAPSE. 

Prolapse  of  the  rectum  is  not  uncommon  in  young  children.  It  is 
usually  produced  by  straining  from  various  causes,  especially  in  extreme 
constipation  or  in  diarrhoea.  The  wall  of  the  rectum  comes  down  through 
the  anus,  and  is  easily  recognized  by  the  appearance  of  the  mucous  mem- 
brane. The  prolapse  is  ordinarily  transitory,  but  in  the  more  severe  forms 
the  rectum  remains  down. 

Treatment. — The  treatment  is  to  remove  the  cause.  Constipation 
should  be  relieved  first  by  enemata  and  then  by  keeping  the  movements 
of  the  bowels  semi-liquid  by  means  of  gentle  laxatives.  The  tenesmus  ac- 
companying diarrhoea  may  be  relieved  by  sponging  with  ice- water  or  by  the 
use  of  0.015  gramme  (J  grain)  suppositories  of  cocaine.  The  child  should 
be  kept  in  bed  for  a  number  of  days,  the  protrusion  being  gently  pushed 
back  each  time  that  it  comes  down.  The  prolapse  should  be  reduced  with 
the  fingers  well  oiled,  the  central  portion  being  pushed  back  first.  If  the 
parts  are  very  sensitive  the  reduction  is  facilitated  by  the  application  of  a 
solution  of  cocaine.  After  reposition  it  should  be  kept  in  place  by  means 
of  a  pad  and  a  T  bandage.  Under  this  treatment  a  large  number  of  cases 
recover.  The  more  serious  and  intractable  cases,  however,  should  be 
referred  to  a  surgeon. 

HEMORRHOIDS. 
Hemorrhoids  are  rarely  met  with  in  infancy  or  early  childhood,  but 
can  occur  and  should  be  treated  by  the  same  methods  as  in  later  life. 

NEW  GROV7THS. 

New  growths  in  the  enteric  tract  are  very  rare  in  infancy  and  child- 
hood, and  are  mostly  confined  to  the  myxomatous  polypi  of  the  rectum. 

Polypus  of  the  rectum  is  more  common  in  early  life  than  at  any  other 
period.  Hemorrhage  from  the  rectum,  when  not  due  to  constipation,  diar- 
rhoea, or  fissure,  usually  arises  from  polypi.  A  careful  examination  for  this 
growth  should  be  made  when  rectal  bleeding  is  frequent  or  large.  Rectal 
polypi  are  of  various  sizes,  and  may  be  myxofibromata  or  adenomata.  The 
surface  of  the  polypus  is  usually  smooth,  and  the  pedicle  is  often  long  and 
thin.  The  diagnosis  is  easily  made  by  a  digital  examination.  The  treatment 
is  either  to  twist  or  cut  off  the  polypus.     The  growth  is  not  apt  to  recur. 

INTESTINAL  DISCHARGES. 

Before  speaking  in  detail  of  the  other  diseases  of  the  intestine,  it  is 
important  to  refer  to  the  contents  of  the  intestine  as  a  whole. 

The  intestinal  contents  should  be  studied  in  regard  to  their  color, 
consistency,    composition,  odor,  and  amount.     The  changes  which  take 


796  PEDIATRICS. 

place  in  the  intestinal  contents  are  significant  of  diseased  conditions, 
but  not  necessarily  of  any  especial  disease. 

Color. — The  color  of  the  ftecal  discharges  varies  greatly,  and  it 
would  be  impossible  to  describe  completely  all  the  variations  from  the 
normal  when  there  is  disturbance  of  the  intestinal  contents.  A  number 
of  the  abnormal  colors  more  usually  seen  are  shown  in  Plate  III.,  facing 
page  77. 

The  square  numbered  16  is  what  is  usually  spoken  of  as  clay-colored. 
This  clay  color  may  be  due  to  a  diminution  in  the  amount  of  bile  which 
enters  the  intestine,  or  to  undigested  fat.  This  color  is  abnormal,  and  is 
usually  met  Avith  in  intestinal  chseases  of  a  subacute  or  chronic  type.  It 
does  not  necessarily  indicate  a  serious  condition,  however,  as  even  a  small 
plug  of  mucus  may  interfere  with  the  flow  of  bile  into  the  duodenum. 

Number  17  may  be  simply  a  change  that  has  taken  place  after  the 
faeces  have  been  passed,  and  wliich  often  is  not  significant  of  any  especial 
pathological  condition.  It  may,  however,  show  that  the  changes  wliich 
have  taken  place  in  the  food  during  its  passage  through  the  intestine  have 
not  been  entirely  normal.  It  is  the  least  important  of  the  changes 
which  take  place  in  the  color  of  the  intestinal  contents.  The  colors  in  18 
and  1 9,  are  Avhat  may  be  seen  in  a  more  serious  disturbance  of  the  en- 
teric tract.  These  colors  may  appear  in  any  of  the  intestinal  diseases 
which  are  accompanied  by  diarrhea,  but  are  significant  of  no  especial 
disease.  They  are  merely  to  be  considered  pathological  in  contradistinc- 
tion to  the  normal  colors  seen  in  3,  4,  6,  7,  8,  9,  and  the  beginning  ab- 
normal condition  represented  in  17. 

Besides  these  shades  of  green  there  are  a  great  many  varieties  of  color 
produced  by  the  mixture  of  green,  yellow,  white,  and  brown.  These  are 
valuable  merely  as  instructing  us  whether  we  are  deahng  with  a  normal 
or  an  abnormal  condition  of  the  intestinal  contents,  and  are  not  sig- 
nificant of  any  one  disease,  either  functional  or  organic.  Much  variety  in 
the  color  also  arises  from  the  admixture  of  blood,  mucus,  and  shreds  of 
membrane.  In  this  connection  it  is  well  to  remember  that  the  yellowish- 
white  lumps  seen  in  undigested  faeces  are  often  made  up  of  fat  as  well  as 
of  proteid  material. 

The  color  of  the  intestinal  contents  may  also  be  changed  by  the  ad- 
ministration of  various  drugs,  such  as  iron,  which  causes  a  more  or  less 
black  color.  Bismuth  gives  the  colors  which  are  seen  in  12,  13,  and  14. 
Number  12  is  the  color  which  was  produced  by  giving  to  an  infant  0.18 
gramme  (3  grains)  of  bismuth  every  two  hours  for  six  doses  ;  number  13, 
when  0.24  gramme  (4  grains)  of  bismuth  was  given  every  two  hours  for 
six  doses ;  and  number  14,  when  the  latter  dose  had  been  omitted  for 
twenty-four  hours.  The  size  of  the  dose  and  the  intervals  between  its 
administration  will  of  course  produce  different  shades  of  color. 

When  the  solids  of  the  intestinal  contents  are  much  reduced  in  pro- 
portion to  the  serum,  as  in  cases  of  acute  and  frequent  diarrhoea,  the  dis- 


DISEASES   OF   THE   INTESTINE.  797 

charges  become  more  and  more  fluid,  and  sometimes  almost  entirely  lose 
their  color  and  look  like  water. 

CoNsisTEXCY. — In  the  first  year  of  life,  or  while  the  infant  is  having 
only  milk  for  its  food,  the  consistency  of  the  faecal  discharges  is  inter- 
mediate between  sohd  and  fluid,  and  the  discharge,  as  a  rule,  is  smooth 
and  free  from  lumps.  As  the  infant  begins  to  take  other  forms  of  food 
and  a  mixed  diet,  the  fcecal  discharges  gradually  become  more  solid.  The 
consistency  of  the  ftecal  discharge  is  abnormal  when  it  becomes  liquid,  as 
in  diarrhoea,  or  when  it  is  too  solid,  as  in  constipation. 

Composition, — In  addition  to  the  various  substances  which  make  up  the 
food  which  enters  the  intestine,  the  fsecal  discharges  contain  bile,  mucus, 
epithelial  remains,  and  numerous  bacteria  of  many  varieties.  In  diseased 
conditions  they  may  also  contain  certain  morbid  elements,  such  as  blood, 
pus,  and  membrane.  In  intestinal  diseases  of  both  an  acute  and  a 
chronic  type  the  mucus  may  be  very  largely  increased,  but  it  cannot  be  con- 
sidered to  be  especially  characteristic  of  an  inflammatory  condition,  as  the 
secretion  of  mucus  apparently  may  be  very  much  increased  in  purely 
functional  conditions. 

Odor. — ^AVhile  in  the  normal  fcecal  discharges  of  infants  fed  entirely 
on  milk  the  odor  is  comparatively  slight,  it  becomes  much  stronger  as 
other  articles  of  food,  either  of  a  starchy  or  of  a  proteid  nature,  are  added 
to  it.  AVhen  an  alDuormal  condition  exists,  various  changes  take  place,  as 
in  acid  fermentation,  in  which  the  odor  is  supposed  to  be  sour,  and  in 
albuminous  decomposition,  in  which  the  odor  is  supposed  to  be  very  foul, 
but  these  distinctions  cannot  with  our  present  knowledge  be  said  to  be 
definitely  proved.  Although  these  can  scarcely  as  yet  be  considered  of 
great  diagnostic  importance,  they  are  sufficiently  so  for  us  to  make  use  of 
them  in  the  diagnosis  and  treatment  of  intestinal  diseases.  Thus,  when 
acid  fermentation  is  supposed  to  be  present,  a  reduction  in  the  percentage 
of  the  sugar  is  indicated,  while  when  albuminous  decomposition  is  sus- 
pected a  reduction  of  the  proteids  in  the  food  is  called  for. 

Amount. — In  estimating  the  amount  of  the  ftecal  discharges  we  must 
consider  the  total  amount  in  twenty-four  hours,  and  not  the  large  or  small 
amount  which  may  occur  at  one  movement.  The  total  amount  in  twenty- 
four  hours  is  of  much  importance  in  both  the  acute  and  the  chronic  dis- 
eases of  the  intestine.  In  the  acute  diseases,  the  more  frequent  the  diar- 
rhoea and  the  larger  the  amount  the  greater  is  the  exhaustion  and  the 
worse  is  the  prognosis.  In  some  chronic  diseases  the  total  amount  of 
fascal  discharges  may  be  very  large.  In  these  cases  the  larger  the  total 
amount  the  less  has  been  the  absorption  and  the  worse  is  the  prognosis, 
for  this  condition  is  an  indication  that  the  child  is  being  starved  from  a 
lack  of  power  to  absorb  the  food  which  has  been  given  to  it. 

FUNCTIONAL. 

Functional  diseases  of  the  intestine  are  represented  by  (a)  incontinence, 
(6)  constipation,  (c)  nervous  diarrhcea,  and  (d)  indigestion. 


798  PEDIATRICS. 

INCONTINENCE   OF  F^CBS. 

Incontinence  of  feces  is  a  condition  in  which  the  fa3cal  movements 
occur  invokmtarily.  This  may  be  due  to  inabihty  to  control  the  sphincter 
ani,  or  to  loss  of  power  of  the  sphincter  itself.  The  first  class  of  cases, 
due  to  disease  or  injury  of  the  spinal  cord,  or  to  absence  of  reflex  sen- 
sation, is  rare.  The  second  class  is  due  to  an  atonic  condition  of  the 
sphincter.  The  treatment  of  the  first  class  of  cases  is  essentially  that  of 
the  disease  in  which  it  occurs.  The  treatment  of  the  second  class  is 
illustrated  in  the  following  cases : 

A  boy,  eleven  years  old,  much  overworked  at  school,  had  been  made  to  study  a 
number  of  languages,  and  allowed  to  take  only  a  very  limited  amount  of  exercise  in  the 
open  air.  He  completely  lost  control  of  the  sphincter  ani,  and  became  very  anfemic 
and  weak.  Nothing  abnormal  was  found  on  a  physical  examination.  The  boy  was 
taken  from  school,  relieved  entirely  of  his  studies,  and  kept  in  the  open  air  most  of 
the  day.  Under  this  treatment,  in  addition  to  the  administration  of  tartrate  of  iron 
and  potassium  and  claret,  he  improved  rapidly,  and  in  two  months  was  entirely  well. 

Another  boy,  seven  years  old,  came  to  the  Children's  Hospital,  w^ith  a  history  of 
incontinence  of  faeces  lasting  over  a  year.  He  illustrated  the  condition  of  incontinence 
from  habitual  constipation,  as  the  incontinence  was  found  to  depend  on  the  stretching 
of  the  rectum  by  impacted  faeces.  The  rectum  was  emptied  by  a  dose  of  castor  oil  and 
an  enema  each  day.  At  the  end  of  a  week  the  boy  had  ceased  to  have  involuntary 
faecal  movements,  and  has  since  continued  well. 

CONSTIPATION. 

By  constipation  is  meant  a  condition  in  which  the  movements  of  the 
bowels  do  not  take  place  as  often  as  is  normal  for  the  individual,  and  in 
which  the  consistency  is  abnormally  increased.  Constipation  is  a  symp- 
tom and  not  a  disease.  It  is  a  relative  term,  as  what  would  be  normal  in 
one  individual  may  be  abnormal  in  another.  During  the  first  year  of  life 
two  or  three  daily  discharges  may  be  considered  normal,  in  the  second 
year  two  discharges,  and  in  the  third  and  fourth  years  one  discharge  is  the 
usual  number.  The  causes  of  constipation  are  varied  and,  in  many  cases, 
father  obscure.  They  may  be  mechanical,  but  are  usually  functional,  and 
either  spasmodic  or  atonic.  As  the  sigmoid  flexure  is  proportionately 
long  in  infancy,  flexions  may  occur  with  the  result  of  producing  a  me- 
chanical obstruction. 

Spasmodic. — The  spasmodic  cases  are  rare,  but  should  be  recognized, 
as  they  frequently  cause  much  disturbance  of  the  child's  general  health. 
They  are  usually  due  to  fissures  about  the  anus  or  to  an  increased  size 
and  consistency  of  the  feeces,  which,  by  causing  pain  in  defecation,  result 
in  spasmodic  closure  of  the  sphincter. 

Treatment. — The  treatment  of  the  spasmodic  cases,  when  the  cause 
is  from  fissure  or,  as  in  some  instances,  from  hemorrhoids,  is  descrODed 
on  page  795.  When  an  abnormal  size  or  consistency  of  the  faeces  is  pro- 
ducing the  spasm,  the  rectum  should  be  thoroughly  emptied  for  a  number 


DISEASES    OF   THE    INTESTINE.  799 

of  days  by  mechanical  means.  This  may  be  in  the  form  of  enemata  of 
equal  parts  of  glycerin  and  water,  or  in  extreme  cases  by  using  the  finger, 
well  oiled,  to  break  up  and  draw  out  the  pieces.  The  subsequent  treat- 
ment would  be  the  same  as  described  below  in  the  atonic  cases.  The 
size  of  the  fa?cal  masses  may  at  times  be  enormous,  and  in  these  cases  a 
mechanical  dilatation  of  the  rectum  may  result.  Gradual  dilatation  of  the 
sphincter  Avith  bougies  two  or  three  times  a  week  has  proved  a  valuable 
adjunct  to  the  treatment  of  these  more  severe  cases,  the  rectum  gradually 
recovering  its  normal  calilDer. 

Atonic. — The  atonic  is  the  most  common  form  of  constipation,  and 
simply  represents  a  sluggish  condition  of  the  intestinal  peristalsis.  This 
may  arise  from  weakness  of  the  intestinal  muscles.  A  weakened  condi- 
tion may  result  from  a  child  not  being  taught  to  have  its  bowels  moved  at 
regular  times.  The  lack  of  exercise  which  is  so  common  in  the  child's 
life  during  the  winter  months  accounts  for  many  cases  in  which  during  the 
summer  montlis,  when  the  child  is  out  of  doors  playing  all  day,  the  bowels 
are  no  longer  constipated.  Any  disease  of  a  debilitating  nature,  as  well 
as  the  indiscriminate  use  of  laxative  drugs  may  cause  this  weakness  of 
the  intestinal  muscles.  The  most  common  of  all  the  causes,  however,  is 
the  food,  which  is  insufficient  in  amount  or  improper  in  quality  for  the 
digestion  of  the  especial  child.  In  infants  who  are  being  fed  exclusively 
on  milk,  a  low  percentage  of  fat  in  the  milk  seems  in  a  number  of  cases 
to  produce  constipation.  We  have  noticed,  however,  that  when  a  breast- 
milk  contains  a  low  percentage  of  fat  and  a  high  percentage  of  proteids 
the  faecal  movements  are  thin  and  watery.  In  some  cases  boiling,  or 
even  pasteurizing,  the  milk  produces  obstinate  constipation,  but  in  many 
cases  no  such  condition  is  produced.  In  young  children  a  lack  of  the 
proper  amount  and  combinations  of  vegetables,  meats,  and  fruits  is  a  very 
common  cause  of  constipation. 

Symptoims. — In  addition  to  the  usual  symptoms  of  mfrequency  of  defe- 
cation, straining,  and  increased  consistency  of  the  faeces,  there  are  others 
which  are  often  overlooked.  There  may  be  general  nervous  symptoms, 
such  as  fretfulness,  apathy,  insomnia,  and  pain  varying  in  its  locality, 
sometimes  being  prominent  in  the  head  and  sometimes  in  the  abdomen. 
It  is  not  uncommon  to  find  streaks  of  blood  mth  the  fseces  when  the 
strain  is  excessive.  ' 

Diagnosis. — The  diagnosis  of  the  condition  of  constipation  is  self-evi- 
dent ;  the  difficulty  arises  in  detecting  the  cause  and  locating  the  part  of 
the  intestine  in  which  the  atonic  condition  exists.  When  it  is  the  rectum 
that  is  chiefly  affected  there  are,  as  a  rule,  no  especial  symptoms  wliich 
cannot  be  relieved  by  the  use  of  enemata  or  suppositories  ;  when  it  is  the 
upper  part  of  the  small  intestines  the  symptoms  connected  with  intestinal 
indigestion  aid  us  in  the  diagnosis. 

Prognosis. — As  a  rule,  constipation  can  be  easily  cured,  but  some 
cases  are  extremely  intractable  and  last  for  a  number  of  years.     In  the 


800  PEDIATRICS. 

mechanical  cases,  as  soon  as  the  intestine  has  become  more  developed 
and  assumed  the  relative  proportions  found  in  adult  life,  the  constipation 
is  very  apt  to  pass  away ;  so  in  these  cases  we  may  give  a  favorable  prog- 
nosis. 

Treatment. — The  treatment  of  the  atonic  cases  is  to  remove,  when 
possible,  the  causes  which  have  already  been  cited,  and  to  give  the  proper 
treatment  to  the  disease  from  which  the  constipation  has  resulted.  Regu- 
lar habits  as  to  the  movement  of  the  bowels,  exercise,  and  meals  are  very 
important. 

JDiet. — Reliance  should  be  placed  on  the  regulation  of  the  diet,  rather 
than  on  drugs,  which  should,  as  a  rule,  be  looked  upon  as  of  only  tempo- 
rary use.  When  the  infant  is  being  fed  on  modified  milk,  we  should  re- 
member that  a  variation  in  the  percentage  of  the  sugar,  as  well  as  of  the 
fat,  may  produce  constipation  in  certain  individuals.  During  the  first  year 
the  percentages  to  be  obtained  as  soon  as  possible  are : 

Fat  4.00 

Sugar 7.00 

Protcids '2.00  to  2.50 

During  the  second  year  whole  cow's  milk,  with  the  addition  of  cream, 
should  be  given.  It  is  often  advisable  to  reduce  the  amount  of  cereals 
and  increase  the  amount  and  variety  of  vegetables  and  fruits.  Of  the 
latter,  baked  apples,  orange-juice,  stewed  prunes,  and  ripe  peaches  are 
especially  indicated.  Broths  and  meat-juices  should  also  be  given,  and  as 
the  child  grows  older,  sometimes  at  two  years,  butter,  and  at  two  and  a 
half  years  meat,  should  be  added  to  the  diet.  Hot  or  cold  water  given 
before  breakfast,  either  with  or  without  orange-juice,  is  often  efficacious. 
Massage  of  the  abdomen  in  certain  cases  of  obstinate  constipation  has  been 
a  most  successful  form  of  treatment.  Suppositories  of  either  gluten  or 
glycerin  are  especially  efficacious  when  the  rectum  is  chiefly  at  fault. 
Enemata,  cither  of  soapsuds  and  water  or  equal  parts  of  glycerin  and 
water,  are  very  useful  in  temporarily  removing  the  symptoms  until  the 
-  more  radical  form  of  treatment  by  the  regulation  of  the  diet  is  thoroughly 
established. 

Drugs. — When  drugs  are  indicated,  purgatives  and,  as  a  rule,  laxatives 
should  be  given  but  sparingly,  and  only  with  the  idea  of  giving  tempo- 
rary relief,  hi  older  children,  cascara  can  be  given,  either  in  the  form  of 
the  elixir,  3.75  to  7.50  c.c.  (1  to  2  drachms),  or  the  fluid  extract,  0.18  to 
0.3  c.c.  (3  to  5  minims).  Nux  vomica,  according  to  the  age  of  the  child,  is 
especially  valuable  in  the  form  of  the  tincture,  0.12  to  0.24  c.c.  (2  to  4 
minims).  For  young  infants  the  milk  of  magnesia,  1.88  to  3.75  c.c.  (J  to 
1  drachm),  or  olive  oil,  3.75  c.c.  (1  drachm),  or  phosphate  of  soda,  0.12  c.c. 
(2  grains),  should  be  given.  All  these  drugs  should  be  given  in  as  small 
doses  and  as  seldom  as  is  sufficient  to  produce  a  satisfactory  result,  and 
should  be  omitted  as  soon  as  possible. 


DISEASES   OF   THE   INTESTINE.  801 

ACUTE  NERVOUS  DIARRHCEA. 

In  certain  infants  and  children  whose  nervous  system  is  easily  affected 
exaggerated  peristalsis  causing  diarrhoea  may  arise  from  a  number  of 
causes  without  any  knoAvn  lesions,  fever,  or  gastric  disease.  Among  these 
causes  may  be  cited  heat,  cold,  and  fright.  In  like  manner  in  these 
individuals  foreign  bodies,  food  or  otherwise,  may  by  simple  reflex  irri- 
tation cause  such  a  nervous  disturbance  as  to  produce  diarrhoea.  In  these 
cases  either  the  small  or  the  large  intestine,  or  both,  may  be  affected, 
and,  so  far  as  we  know,  the  mucous  membrane  is  either  normal  or 
simply  hyperaemic.  There  is  more  or  less  serous  exudation.  These 
cases  are  rare  in  comparison  with  the  other  forms  of  diarrhoea,  such 
as  those  which  are  caused  by  bacteria,  and  in  them  intestinal  indigestion, 
intestinal  decomposition  and  intestinal  inflammation  are  not  present  pri- 
marily. 

Symptoms. — The  symptoms  of  nervous  diarrhoea  are  very  apt  to  appear 
suddenly.  There  is  usually  abdominal  pain,  not,  as  a  rule,  of  great  inten- 
sity. At  first  there  are  two  or  three  rather  liquid  yellowish-brown  dis- 
charges occurring  at  intervals  of  perhaps  one-half  or  one  hour,  and  often 
accompanied  by  considerable  flatus.  There  is  a  certain  amount  of  rest- 
lessness, pallor,  and  exhaustion.  Vomiting  is  usually  not  present  and  is 
rarely  excessive.  The  temperature,  as  a  rule,  is  not  raised,  or  is  raised 
very  slightly.  The  pulse  is  rather  weak  and  somewhat  accelerated.  The 
number  of  the  discharges  may  be  eight,  ten,  or  twelve  in  the  twenty-four 
hours,  and  these  soon  become  watery  and  of  a  lighter  color.  The  char- 
acteristic symptoms  of  a  typical  case  are  loose  movements  of  normal 
color  and  odor,  without  abnormal  constituents.  These  symptoms,  unless 
they  are  exaggerated  by  improper  food  or  by  bad  treatment,  usually  dis- 
appear in  a  few  days. 

Treatment. — The  treatment  is  essentially  to  remove  the  cause.  If  the 
cause  is  atmospheric,  a  change  in  climate  is  desirable.  If  undigested  food 
is  causmg  intestinal  irritation,  a  dose  of  castor  oil,  3.75-7.50  grammes 
(drachms  1  to  2),  or  calomel,  .006  gramme  (yV  grain),  every  hour  for  ten 
doses,  may  be  given,  but  as  a  rule  this  is  not  necessary.  The  child 
should  be  kept  in  bed.  Food  should  be  withheld  for  some  hours. 
After  the  cause  has  been  removed,  the  treatment  should  be  to  control  the 
peristalsis  and  the  pain.  For  this  purpose  a  few  drops  of  tincturse  opii 
camphorata  and  hot  applications  to  the  abdomen  are  indicated.  If  there 
is  a  tendency  for  the  diarrhoea  to  continue,  the  subnitrate  of  bismuth  may 
be  given,  and  in  some  cases  when  there  are  signs  of  exhaustion  a  stimu- 
lant may  be  needed.  In  the  cases  in  which  the  excessive  peristalsis  seems 
to  be  prolonged  by  weakness,  brandy  in  small  doses  is  more  useful  than 
astringents  or  opium.  For  several  days  the  diet  should  be  simply  milk 
heated  for  twenty  minutes  at  75°  C.  (167°  F.),  and  containing  ten  per 
cent,  of  lime-water.  These  nervous  diarrhoeas,  especially  in  hot  weather, 
should  never  be  allowed  to  continue,  as  they  render  the  intestine  vulner- 

51 


802  PEDIATRICS. 

able  to  the  more  serious  diseases  caused  by  micro-organisms,  wliich  may 
at  any  moment  gain  an  entrance  in  this  way.  Care  should  be  exercised 
to  see  that  the  child  is  not  overheated  from  too  many  clothes. 

Illustrative  Case. — M.  F.  was  four  months  old,  and  breast-fed.  Two  days  pre- 
viously he  began  to  have  loose  movements.  He  had  averaged  about  seven  movements 
in  twenty-four  hours.  The  movements  were  loose,  yellow,  normal  odor,  no  mucus, 
no  curds,  no  blood.  He  vomited  once.  There  was  no  loss  of  weight.  Examination 
was  negative  and  the  temperature  was  normal.  He  returned  two  days  later.  Mother 
said  the  diarhcea  had  ceased  at  once,  and  that  the  child  was  perfectly  well. 

OHRONIO  NERVOUS  DIARRHCEA. 

In  the  chronic  form  of  nervous  functional  intestinal  disturbance  either 
the  small  or  the  large  intestine  may  be  affected,  and  the  condition  of  the 
mucous  membrane,  so  far  as  we  know,  is  either  normal  or  hypersemic. 
The  causes  are  the  same  as  in  the  acute  form.  This  class  of  cases  is  not 
especially  common,  as  they  are  merely  a  prolongation  of  the  symptoms 
which  we  have  already  sufficiently  described  in  speaking  of  the  acute  cases. 
The  treatment  of  these  cases  is  essentially  with  stimulants  and  care  of  the 
general  health. 

TUBULAR. 

In  addition  to  these  more  common  intestinal  affections  of  nervous 
origin  is  one  that  is  called  tubular.  This  disease  is  so  rare  before  the  age 
of  puberty  that  it  need  only  be  alluded  to.  It  is  a  condition  of  the 
mucous  membrane  of  any  part  of  the  intestine  in  which  an  exudation  of 
mucus  takes  place  in  such  a  way  that  masses  closely  simulating  a  mem- 
brane may  occur  on  the  surface.  When  discharged  through  the  rectum 
they  are  sometimes  found  to  have  formed  a  cast  of  the  intestine.  These 
masses  are  mostly  made  up  of  mucus,  and  may  occur  in  shreds  of  greater 
or  less  extent,  as  well  as  in  the  tubular  form.  The  disease  is  supposed 
to  be  of  nervous  origin. 

Symptoms. — The  symptoms  are  pain,  tenderness,  and  tenesmus.  The 
^    ^temperature  is  usually  normal. 

Prognosis. — The  prognosis,  as  a  rule  is  good,  although  in  some  cases 
the  disease  may  be  much  prolonged. 

Treatment. — The  treatment  is  to.be  directed  towards  the  improvement 
of  the  general  health  and  the  nervous  condition^  the  local  treatment  being 
simply  symptomatic. 

INDIGESTION. 

Disturbances  arising  from  intestinal  indigestion,  although  in  most  cases 
having  their  origin  in  the  duodenum,  seem  also  in  quite  a  number  of  cases 
to  be  located  in  the  intestine  beyond  the  duodenum. 

These  cases  vary  in  their  symptoms  with  the  individual  and  according 
to  the  part  of  the  intestine  which  is  most  involved,     In  one  set  of  cases 


DISEASES   OF   THE   INTESTINE.  803 

the  region  of  the  duodenum  seems  to  be  most  affected,  while  in  another 
the  irritation  is  probably  below  the  duodenum. 

ACUTE  DUODENAL.  INDIGESTION. 
This  condition  is  very  rare  in  infancy,  and  usually  occurs  in  middle 
and  later  childhood.  In  these  cases,  in  addition  to  the  increased  peristalsis 
and  evidence  of  undigested  food,  there  are  frequently  icterus  and  vomiting 
of  bile,  indicating  that  there  is  irritation  in  the  duodenum.  In  addition 
to  these  symptoms  there  may  be  headache  and  excessive  nausea.  The 
icterus  is  usually  slight  in  degree,  but  often  is  marked  and  is  noticeable  in 
the  conjunctivae  and  in  the  urine.  Plate  III,  (facing  page  77),  No.  11, 
shows  the  staining  of  bile  on  the  napkin  from  the  urine  of  an  infant  during 
an  acute  attack  of  indigestion  involving  the  duodenum  and  accompanied 
by  icterus.  The  temperature  in  these  cases  is  usually  slightly  raised  for  a 
few  days  and  then  becomes  subnormal.  In  a  certain  number  of  cases 
the  faecal  discharges  become  clay-colored.  This  color  is  often  produced 
mechanically,  as  has  already  been  explained. 

Prognosis. — Although  the  symptoms  in  these  acute  attacks  may  often 
appear  quite  serious,  the  prognosis  is  always  good.  In  some  individuals 
they  are  liable  to  recur  even  when  the  diet  and  the  general  health  are  well 
attended  to. 

Treatment.— In  the  treatment  of  this  class  of  duodenal  disturbances 
we  must  consider  that  the  fats  in  the  food  are  in  all  probability  especially 
liable  to  prolong  the  disease  by  not  being  properly  digested  so  long  as  the 
function  of  the  duodenum  is  involved.  We  should,  therefore,  in  treating 
these  cases,  lessen  the  amount  of  fat  given  in  the  food.  We  have  found 
that  the  treatment  which  most  speedily  shortens  the  attack  is  (1)  total 
restriction  from  food  for  twelve  hours,  with  the  administration  of  small 
quantities  of  cold,  sterilized  water  if  the  thirst  is  excessive,  and  (2)  the 
administration  of  small  quantities  of  milk  modified  as  in  the  following 
prescription : 

Peescription  47. 

Fat 0.00 

Sugar 4.00 

Proteids 3.00 

Lime-water •. , . .  . , 10.00 

The  mixture  to  be  heated  to  75°  C.  (167°  F.)  for  twenty  minutes  ;  from 
120  to  240  c.c.  (from  4  to  8  ounces),  according  to  the  age,  to  be  given 
every  three  hours.  In  some  cases  also  the  diet  of  proteids  may  be  varied 
by  giving  expressed  beef-juice  or  solutions  of  white  of  egg. 

Under  this  treatment  the  icterus  usually  passes  away  in  a  few  days, 
and  the  child  can  then  soon  be  given  its  ordinary  food. 

CHRONIC  DUODENAL  INDIGESTION. 
The  chronic  form  of  functional  intestinal  indigestion  plays  an  important 
part  in  the  intestinal  disease,  especially  when  it  is  located  in  the  duodenum. 


806  PEDIATRICS. 

be  somewhat  varied  by  giving  fish  and  eggs,  and  the  percentage  of  Hme- 
water  in  the  milk  may  be  reduced  to  five.  As  relapses  occur  very  easily, 
however,  it  is  generally  best  to  continue  with  this  rigid  diet  until  the  fecal 
discharges  have  become  normal  in  color  and  have  not  shown  the  presence 
of  mucus  for  a  nmnber  of  weeks.  In  mild  cases  when  there  is  much 
constipation,  small  doses  of  calomel,  or  any  mild  laxative,  are  indicated. 
Podophyllin  can  also  be  given,  as  in  this  prescription  (Prescription  48) : 

Prescriptiox  4S. 

Metric.  Apothecary^ 

Grammes. 

R    Podophvllin 0  C>6      R     Podophyllin gr.  i ; 

Alcohol 3  75  Alcohol 5  i. 

M.  M. 

Sig. — From  3  to  5  drops,  according  to  the  age  of  the  child,  in  the  morning  and  even- 
ing, lessening  the  dose  if  it  causes  more  than  two  discharges  daily. 

"\Mien  there  is  a  tendency  to  diarrhcea,  bismuth  is  valuable.  See  pages 
811  and  812. 

Tincture  of  nux  vomica  freely  diluted  in  water  and  given  in  doses  of  a 
few  drops  before  each  meal  seems  in  some  cases  to  be  of  value,  especially 
after  the  function  of  digestion  has  shown  signs  of  improvement. 

The  remainder  of  the  treatment  is  essentially  symptomatic,  and  if  the 
children  are  weak  and  anaemic  tartrate  of  iron  and  potassium  can  be  given. 
See  page  893. 

During  the  whole  course  of  this  disease  cod-liver  oil  is  contra-indicated, 
but  when  the  disease  has  been  cured  and  the  child  is  left  weak  and  emaci- 
ated it  may  in  some  cases  be  benelicial.  Its  admmistration,  however, 
should  always  be  carefully  supervised,  as  it  may  cause  a  relapse.  The 
specially  restricted  diet  should  be  contmued  for  some  time  after  the  charac- 
teristic sjTuptoms  of  the  disease  have  disappeared,  or  relapses  ^vill  occur. 

The  following  ease  is  illustrative  of  chronic  indigestion  of  the  duodenum.  A  girl 
six  years  old  and  healthy  at  birth,  was  nursed  until  she  was  thirteen  months  old. 
During  her  first  year  she  had  an  attack  of  bronchitis.  Previous  to  this  attack  she  had 
never  had  any  intestinal  disturbance.  Her  abdomen  was  always  rather  prominent. 
From  her  earliest  infancy  she  had  been  a  nen-ous  child,  had  not  slept  well,  had  talked 
much  in  her  sleep,  and  had  occasionally  walked  in  her  sleep.  During  the  first  six 
months  of  the  disease  the  symptoms  w^ere  chiefly  loss  in  weight  and  cough.  She  then 
had  an  attack  characterized  by  vomiting  for  twenty-four  hours,  followed  by  anorexia, 
fever,  languor,  and  apathy  ;  the  bowels  became  constipated,  the  skin  icteric,  the  urine 
dark-colored,  and  the  fecal  movements  Ught-colored.  She  had  an  intense  craving  for 
sugar,  and  ate  all  that  she  could  lay  her  hands  on.  so  that  she  had  to  be  watched  very 
closely  to  prevent  her  satisfjing  this  morbid  appetite.  Her  appetite  for  other  articles 
of  food  was  poor.  The  abdomen  was  distended  and  tympanitic,  and  the  tongue 
coated.  The  breath  had  a  disagreeable  odor,  and  there  was  loss  of  flesh.  There  was 
a  follicular  pharyngitis,  which  evidently  caused  the  cough. 

The  child  was  placed  on  the  following  diet.  Her  first  meal  was  milk  so  modified 
as  to  contain  fat  2,  sugar  4,  proteids  3,  lime-water  10.  With  this  meal  she  was 
allowed  to  have  a  small  amount  of  the  crust  of  French  bread.     The  second  meal  con- 


DISEASES    OF    THE    IXTESTINE.  807 

sisted  of  broth  and  the  crust  of  French  bread,  and  one  ounce  of  claret  in  half  a  tum- 
bler of  seltzer  water.  The  third  meal  consisted  of  meat,  the  crust  of  French  bread, 
claret,  and  seltzer  water ;  the  fourth,  of  soup,  the  crust  of  French  bread,  claret,  and 
seltzer  water ;  the  fifth  of  the  modified  milk  and  the  crust  of  French  bread.  Before 
each  meal  three  drops  of  tincture  of  nux  vomica  were  administered. 

This  diet  was  carried  out  vigorously  for  one  week.  At  the  end  of  that  time  the 
child  looked  much  better,  the  urine  was  clear,  the  faecal  movements  began  to  resume 
a  more  natural  color,  the  mucus  in  the  discharges  was  very  much  lessened,  and  the 
abdomen  was  not  so  much  distended.  The  tongue  was  less  coated,  and  the  cough 
had  almost  disappeared.  It  was  also  found  that  the  craving  for  sugar  had  much  de- 
creased. The  diet  was  then  slightly  increased  in  variety.  At  the  end  of  a  month  the 
child  had  recovered  entirely,  and  some  weeks  later  an  ordinary  diet  at  the  usual  times 
was  given  to  her. 

INTESTINAL  INDIGESTION. 

Although  there  is  often  no  marked  hne  to  be  drawn  between  disturb- 
ances of  digestion  which  occur  in  difierent  parts  of  the  intestine,  }'et 
clinically  a  distinction  can  be  made  often  enough  to  separate  for  purposes 
of  classification  the  duodenal  form  just  spoken  of  from  those  cases  in  which 
the  indigestion  seems  to  be  located  below  the  duoilenum  and  ^vhicli  for 
want  of  a  better  name  may  be  called  intestinal.  There  seems  also  to  be  a 
clinical  difterence  in  these  cases  according  to  whether  the  indigestion  shows 
the  presence  of  undigested  food  alone  or  is  accompanied  by  evidence  of 
bacterial  action,  as  shown  by  signs  of  fermentation.  Both  forms,  however, 
merge  so  closely  that  they  must  clinically  be  considered  as  representing 
two  t}"pes  of  the  same  class.  The  first  type,  which  depends  principally 
upon  the  action  of  the  intestinal  secretions  on  the  food,  may  be  designated 
deficient  secretion,  the  other  jennentafion.  Both  types  may  be  acute  or 
chronic. 

Deficient  Secretion. — By  deficient  secretion  we  mean  that  the  intestinal 
secretions  are  not  sufficient  either  in  c{uantity  or  c|uality  to  digest  the  food. 
The  secretions  may  be  normal  and  the  food  excessive,  or  the  secretions 
may  be  deficient  and  the  food  normal.  The  result  is  practically  the  same, 
the  disturbance  between  the  intestinal  secretions  and  its  contents  pro- 
ducing indigestion.  In  these  cases,  however,  abnormal  fennentation  does 
not  play  a  prominent  part. 

Heat  as  an  etiological  factor  is  very  important  in  both  these  types 
of  indigestion,  by  producing  functional  disturbance  of  the  chgestion  with 
consequent  interference  with  the  metabolism.  Under  these  conditions  the 
undigested  food  acts  as  an  irritant  and  is  the  cause  of  the  diarrhoea.  In 
tj'pical  cases  of  this  class  there  are  no  lesions  in  the  intestines. 

Symptoms. — As  the  symptoms  of  intestinal  indigestion  depend  upon 
the  degree  of  the  deficiency  of  secrftion.  the  onset  of  the  diarrlKTE-a  may 
be  gradual  or  sudden. 

Abdominal  pain  and  vomiting  may  or  may  not  be  present.  When 
present  they  usually  precede  the  diarrhcea.  The  movements  are  loose, 
rather  lara-e  in  amount,  varv  six  to  twelve  in  the  twentv-four  hours,  and 


808  PEDIATRICS. 

are  usually  free  from  much  odor.  The  color  is  a  mixture  of  yellow,  brown, 
and  white,  the  latter  caused  by  the  presence  of  curds  of  various  sizes. 
There  may  also  be  a  light  greenish  color,  but  the  deeper  shades  of  green 
are  not  common  as  in  the  fermental  type.  There  may  or  may  not  be  a 
small  amount  of  mucus.  Blood  is  seldom  present,  and,  as  a  rule,  only 
appears  after  the  attack  has  lasted  for  some  time,  an  important  point  of 
distinction  from  the  infectious  cases  in  which  the  blood  appears  early  in 
the  attack.  The  temperature,  as  a  rule,  is  normal  or  only  slightly  raised, 
and  is  of  brief  duration.  As  a  rule,  there  is  a  moderate  loss  of  weight. 
This  class  of  cases  has  in  its  symptoms  so  much  in  common  with  the 
fermental  type  that  its  remaining  etiology  and  symptomatology  can  be 
described  with  the  latter. 

Prognosis. — The  prognosis  when  the  case  is  properly  treated  is  good. 

Treatment. — The  treatment  is  the  same  as  will  be  described  for  the 
fermental  type  of  intestinal  indigestion. 

Fermentation. — The  type  of  intestinal  indigestion  in  which  fermentation 
plays  a  prominent  role  represents  the  most  severe  class  of  the  non-infec- 
tious forms  of  diarrhoea,  and  in  combination  with  the  previous  type  (that 
of  deficient  secretion)  is  by  far  the  most  common  of  all  cases  of  diarrhoea. 
In  its  typical  form  it  is  characterized  by  the  symptoms  of  indigestion  just 
described  with  the  addition  of  markedly  green  discharges  of  foul  odor,  and 
by  toxic  symptoms  caused  by  the  absorption  of  toxines,  developed  by  bac- 
teria which  are  leading  a  saprophytic  existence  in  the  intestine.  This  class 
of  cases  is  on  the  boundary-line  between  the  non-infectious  and  infectious 
diseases  of  the  intestine.  In  all  cases  it  cannot  be  differentiated  from  the 
infectious  form,  but  in  the  great  majority  of  cases  it  probably  depends 
upon  abnormal  fermentation  and  had  therefore  at  present  better  be  con- 
sidered as  non-infectious.  In  typical  cases  of  this  class  although  there  may 
be  a  hyperaemic  condition  of  the  mucous  membrane  from  irritation,  the 
disturbance  is  functional  and  there  are  no  lesions. 

Etiology. — Impure  or  improper  foods,  bad  hygienic  surroundings,  pro- 
longed hot  weather,  or  anything  which  inhibits  the  process  of  digestion, 
^afford  an  opportunity  for  the  increased  development  of  the  bacteria  always 
present  in  the  intestine  and  for  fermentation  of  the  intestinal  contents.  It 
should  be  noted  that  the  clinical  manifestations  of  these  cases  of  fermental 
diarrhoea  show  no  essential  differences  whether  they  occur  in  the  winter  or 
summer  months.  They  are  more  common  in  the  summer  and  autumn 
because  of  greater  prevalence  of  the  exciting  causes  at  that  time. 

While  it  must  be  admitted  that  in  many  cases  the  source  of  bacterial 
infection  is  from  infected  food  from  without,  yet  as  Dunn  has  shown  by 
his  study  of  over  six  hundred  cases  in  the  summer  of  1903,  heat  in  itself 
must  be  a  very  prominent  etiologic  factor  in  producing  bacterial  action 
within  the  intestine.  Exactly  how  the  heat  acts  is  theoretical.  It  is  plau- 
sible to  suppose  that  the  increased  and  prolonged  heat  either  through  dis- 
turbance of  the  nervous  or  circulatory  system,  or  of  both  diminishes  the 


DISEASES  OF  THE  INTESTINE.  809 

secretion  of  the  digestive  fluids.  Curds  are  therefore  not  properly  digested 
and  broken  up,  and  thus  sufficient  irritation  arises  to  produce  diarrhoea. 
The  secretion  of  fluids  known  to  be  antiseptic,  or  at  least  to  inhibit  bac- 
terial development  is  diminished,  thus  allowing  opportunity  for  increased 
development  of  the  bacteria  which  are  always  in  the  intestine,  and  pro- 
ducing the  fermental  cases  of  diarrhoea. 

Symptoms. — The  onset  may  be  subacute,  with  little  or  no  fever  and 
without  vomiting,  or  it  may  be  acute  and  accompanied  by  a  high  tempera- 
ture and  active  vomiting.  After  a  variable  period  of  general  discomfort  and 
restlessness,  diarrhoea  sets  in.  The  onset  of  fermental  diarrhoea  is  so  often 
characterized  by  the  toxic  symptoms  of  sudden  rise  of  temperature,  followed 
after  a  day  or  so  by  a  normal  temperature,  that  w^hen  we  meet  with  this 
occurrence  w^e  are  usually  justified  in  eliminating  true  infection  of  the  walls 
of  the  intestines  as  a  cause  of  the  diarrhoea.  In  some  cases  the  diarrhoea, 
although  accompanied  by  much  prostration  and  various  ner^^ous  disturb- 
ances, disappears  after  a  few  days  ;  in  others,  especially  in  tlie  warm 
weather,  it  may  last  for  a  number  of  months,  and  eventually  develop  into 
an  infectious  type. 

In  fermental  diarrhoea  the  color  of  the  discharges  is  commonly  some 
shade  of  green  or  greenish  yellow,  and  the  odor  is  often  very  offensive, 
sometimes  being  excessively  sour  in  which  case  it  is  supposed  to  arise 
from  acid  fermentation,  and  at  other  times  extremely  foul  indicating  albu- 
minous decomposition.  The  chscharges  are  generally  accompanied  by 
considerable  pain  and  a  large  amount  of  gas.  They  usually  are  large  in 
amount,  and  accordmg  to  the  severity  of  the  case  vary  in  number  from 
twelve  to  twenty,  there  is  usually  a  considerable  amount  of  mucus  present. 
The  symptoms  are  often  so  severe  that  the  disease  has  a  serious  aspect, 
but  in  a  considerable  number  of  cases  after  the  intestine  has  been  thor- 
oughly emptied  the  temperature  falls  and  the  nervous  symptoms  subside. 
In  some  of  the  more  severe  cases  certain  special  symptoms  become  so 
l^rominent  as  to  produce  almost  different  types  of  the  disease.  The  most 
important  of  these  are  excessive  vomiting,  continuous  hyperpyrexia,  and 
extreme  restlessness  with  insomnia.  There  is  usually  rapid  and  great  loss 
of  w^eight.  In  cases  which  are  not  prolonged  by  fresh  irritation  or  by 
unwise  treatment  recovery  often  takes  place  quite  rapidly.  According  to 
Morse,  albuminuria  occurs  in  about  fifteen  per  cent,  of  all  cases.  Casts, 
usually  hyaline  and  fine  granular,  occur  m  about  sixty  per  cent,  of  the 
cases  of  albuminuria.  The  renal  condition  in  these  cases  is  a  degenerative 
one,  and  not  a  true  nephritis. 

Diagnosis. — When  the  attack  is  subacute,  with  slow  onset,  without 
vomiting,  and  with  infrequent  discharges,  the  diagnosis  is  not  difficult,  but 
is  to  be  made  from  the  nervous  diarrhoea,  which  can  usually  be  excluded 
by  the  presence  of  fever,  the  character  of  the  movements  and  by  its  more 
prolonged  and  serious  symptoms.  When,  however,  the  onset  is  acute  and 
is  accompanied  by  vomiting,  the  chagnosis  must  often  be  held  in  abeyance, 


810  PEDIATRICS. 

as  the  symptoms  of  high  temperature,  vomiting,  and  diarrhoea  may  be 
present  in  infants  and  young  children  in  the  initial  stage  of  a  number  of 
acute  diseases.  The  disease  from  which  it  is  especially  to  be  differen- 
tiated is  cholera  infantum.  In  fermental  diarrhoea  the  prostration  is 
much  less,  and  the  temperature  after  the  early  hours  of  the  attack  is 
much  lower.  The  serous  discharges  and  the  continuous  vomiting  which 
soon  arise  in  cholera  infantum  are  quite  different  from  the  greenish  dis- 
charges and  the  less  frequent  vomiting  which  occur  in  fermental  diarrhoea. 
We  must  remember,  however,  that  cholera  infantum  and  the  acute  intes- 
tinal diseases  caused  by  infection  with  special  bacteria  are  usually  pre- 
ceded for  a  number  of  days  by  this  fermental  form  of  diarrhoea,  and  that 
.  the  special  micro-organisms  which  produce  the  former  disease  gain  an 
entrance  for  themselves  and  their  toxines  by  means  of  the  abnormal 
intestinal  conditions  produced  by  the  fermental  changes.  The  differential 
diagnosis  from  infectious  diarrhoea  is  considered  under  that  disease,  on 
page  818.  It  is  also  well  to  remember  that  gastro-enteric  symptoms  are 
often  so  pronounced  during  the  early  days  of  a  pneumonia  that  they  may 
mask  the  presence  of  that  disease. 

Prognosis. — In  previously  healthy  children  the  prognosis  of  fermental 
diarrhcKa  is  good.  It  depends,  however,  upon  the  amount  of  resistance  to 
these  processes  which  the  inchvidual  possesses  and  upon  the  vulnerability 
of  the  individual  to  the  other  bacteria  which  may  at  any  time  complicate 
the  disease  by  the  development  of  an  infectious  diarrhoea.  The  cases  of 
infantile  atrophy  are  especially  liable  to  die  when  attacked  by  this  as  well 
as  by  any  other  form  of  intestinal  disturbance.  In  these  cases  it  seems  as 
though  the  infant  were  totally  unable  to  resist  even  a  slight  amount  of 
toxic  absorption.  The  prognosis,  therefore,  when  an  already  debilitated 
child,  or  one  with  infantile  atrophy,  is  attacked  by  fermental  diarrhoea 
must  always  be  guarded.  It  also  depends  upon  how  soon  and  in  what  way 
the  disease  is  treated.    The  renal  complications  do  not  alter  the  prognosis. 

Prophylaxis. — Much  can  be  done  at  all  seasons  of  the  year  to  pre- 
vent the  occurrence  of  diarrhoea,  but  prophylaxis  is  of  the  utmost  im- 
portance in  warm  weather.  The  children  should  be  protected  by  proper 
clothing  from  extremes  of  heat  and  cold,  and  from  dampness.  They 
should,  if  possible,  be  taken  away  from  crowded  or  unclean  districts  in 
cities  and  towns  during  the  hot  weather,  and  have  the  advantages  of  fresh 
country  or  sea  air  and  good  hygienic  surroundings.  Both  the  quality  and 
the  quantity  of  the  food  should  be  carefully  regulated,  care  being  taken 
not  to  give  too  much  food,  as  the  depression  due  to  heat  weakens  the 
digestive  function.  In  very  hot  weather  an  extra  amount  of  water  should 
be  allowed  and  the  solid  food  somewhat  chminished  in  amount.  As  milk 
is  the  most  common  source  of  infection  in  the  diarrhoeal  diseases,  and  as 
bacteria  multiply  more  rapidly  as  the  weather  becomes  warmer,  it  is  espe- 
cially important  to  have  the  milk  fresh  and  sterile  during  the  summer 
months.     It  must  be  understood  that  not   only  bacteria  but  also   their 


Fk.  in4. 


Colon  showing  presence  of  bismuth  which  had  been  given,  by  the  mouth. 
(Page  811.) 


DISEASES   OF   THE   INTESTINE.  811 

toxines,  which  are  not  destroyed  by  pasteurization  or  sterilization,  may 
produce  most  serious  results.  Uncooked  fruits  and  food  are  contra-indi- 
cated in  very  hot  weather,  and  especial  attention  should  be  paid  to  any 
slight  indisposition  which  may  arise,  as  it  may  render  the  child  more 
vulnerable  to  the  various  causes  of  diarrhoea. 

TREATMENT.^Until  our  knowledge  of  the  specific  infection  of  the  intes- 
tine has  been  sufficiently  advanced  so  that  we  can  give  to  each  disease  its 
specific  treatment,  we  should  practically  carry  out  certain  general  prin- 
ciples in  combating  the  symptoms  of  all  of  them.  These  principles  are  : 
(1)  to  combat  the  nervous  symptoms  ;  (2)  to  dislodge  the  bacteria,  if  sup- 
posed to  be  present,  as  quickly  as  possible,  by  laxatives  and  irrigation  ;  (3) 
not  to  introduce  into  the  gastro-enteric  tract  for  twelve  to  twenty-four 
hours  food  which  may  prove  a  favorable  culture-ground  for  the  bacteria ; 
(4)  to  give  at  the  end  of  this  period  of  starvation  a  very  weak,  strongly 
alkaline,  sterilized  modified  milk,  with  fats  of  from  1  to  2  per  cent.,  sugar 
from  5  to  6  per  cent.,  and  proteids  of  from  .25  to  .50  per  cent. ;  (5)  to  intro- 
.  duce  such  drugs  into  the  gastro-enteric  tract  as  may,  by  their  anti-fermen- 
tative and  germicidal  powers,  diminish  the  action  of  or  destroy  the  bacteria. 
This  last  rule  is,  however,  very  difficult  to  carry  out.  Subnitrate  of  bismuth 
is  the  most  useful  drug  which  we  know  of.  We  know  that  it  reaches  the 
part  of  the  enteric  tract  which  is  generally  most  affected  in  enteric  dis- 
turbances characterized  by  fermentation.  Fig,  1 64  shows  the  intestine  of 
an  infant,  given  to  us  by  Dr.  Holt,  to  illustrate  this  point,  to  whom  bismuth 
had  been  given,  and  in  whom  at  the  autopsy  the  bismuth  was  found  thickly 
coating  the  mucous  membrane  of  the  small  intestine,  and  also  appearing 
in  the  large  intestine.  It  is,  however,  questionable  whether  in  any  case 
the  attempt  to  kill  the  bacteria  by  the  internal  administration  of  drugs  has 
been  successful.  Preparations,  such  as  salol,  which  are  known  to  be 
broken  up  into  their  carbolic  acid  components  on  reaching  the  intestine, 
cannot  with  safety  be  given  to  the  infant  in  doses  large  enough  to  kill  the 
bacteria,  for  in  such  doses  there  may  be  serious  results  from  poisoning. 

The  first  indication  in  the  treatment  of  acute  intestinal  indigestion  is  to 
remove  at  once  the  source  of  the  disturbance  by  thoroughly  emptying  the 
intestine.  When  the  vomiting  is  excessive  it  is  sometimes  necessary  to 
wash  out  the  stomach,  but,  as  a  rule,  this  procedure  is  not  indicated.  A 
dose  of  castor  oil,  one  drachm  for  infants  under  one  year,  and  two  drachms 
for  older  children,  is  the  best  initial  treatment.  When  the  stomach  is  so 
sensitive  that  it  does  not  seem  advisable  to  give  castor  oil,  0.06  to  0.12 
gramme  (1  or  2  grains)  of  calomel  can  be  given  in  divided  doses.  In  the 
more  severe  cases,  when  the  stools  are  very  foul  and  contain  much  mucus 
and  when  there  is  a  tendency  to  a  prolongation  of  the  acute  symptoms, 
irrigation  of  the  intestine  with  hot  salt  solution  once  or  twice  a  day  for 
several  days  is  indicated.  Food  should  be  withheld  for  a  number  of 
hours, — at  least  half  a  day,  if  possible.  Stimulants  are  indicated  when 
there  is  much  prostration.     The  only  other  drug  which  in  our  experience 


812  PEDIATRICS. 

seems  to  be  needed  is  bismuth  subnitrate,  which  should  be  given  in  lai^e 
doses  until  the  disease  has  run  its  course  and  the  diarrhoea  has  ceased. 
The  amount  of  bismuth  in  the  severe  cases  should  be  from  four  to  eight 
grammes  (sixty  to  one  hundred  and  twenty  grains)  in  twenty-four  hours. 
The  milk  of  bismuth  makes  a  very  excellent  preparation  to  use  as  it  may 
be  put  directly  into  the  milk  without  detection  by  the  infant.  One  drachm 
is  equivalent  to  five  grains  of  bismuth  subnitrate. 

Milk  can  in  most  cases  be  given  after  the  first  twelve  to  twenty-four 
hours  if  it  is  properly  modified.  It  should  contain  from  ten  to  fifteen  per 
cent,  of  lime-water,  and  at  first  should  have  the  percentages  of  all  its  ele- 
ments consideralDly  reduced.  The  milk  which  is  used  for  this  purpose 
must  be  fresh,  since  it  is  not  sufficient  to  sterilize  it,  as  the  toxic  products 
of  bacteria  may  still  be  present  in  it  and  thus  add  fresh  irritation  to  that 
which  has  already  been  produced  by  the  fermentation.  In  many  cases  it 
is  impossible  to  determine  what  special  form  of  fermentation  is  present. 
When  acid  fermentation  appears  to  be  prominent,  the  milk  should  be  so 
modified  as  to  contain  a  low  percentage  of  sugar,  while  when  albuminous 
decomposition  with  its  excessively  foul  odor  is  met  with,  and  in  fact  in  all 
cases  of  diarrhoea,  the  proteids  should  be  reduced  to  the  minimum. 

When  breast-milk  or  fresh  modified  cow's  milk  cannot  be  obtained, 
weak  animal  broths,  such  as  those  made  from  mutton,  chicken,  or  beef,  can 
be  used,  but  they  are  distinctly  inferior  to  a  Aveak  modified  milk,  which  if 
sterile  to  begin  with  and  free  from  the  products  of  bacterial  growth,  fur- 
nishes the  best  source  of  food.  Opium  is  almost  invarialDly  contra-indicated 
in  these  cases,  and  serious  results  may  arise  from  its  admmistration.  The 
peristalsis  which  occurs  as  the  result  of  fermental  irritation  is  a  con- 
servative process  of  nature,  intended  to  carry  away  the  morbid  products 
which  have  resulted  from  the  fermentation.  Under  these  conditions  the 
administration  of  opium  prevents  the  elimination  of  the  poison  from  the 
intestine  and  allows  it  to  remain  and  produce  still  further  irritation,  or  to 
be  absorbed  and  give  rise  to  still  graver  septic  symptoms.  Towards  the 
_end  of  the  attack,  when  the  intestine  has  been  thoroughly  emptied,  small 
doses  of  opium  in  the  form  of  tinctura  opii  camphorata  may  be  used  with 
caution  to  diminish  pain  and  to  control  the  excessive  peristalsis  which  may 
result  from  nervous  exhaustion  after  the  disease  has  run  its  course.  In 
these  cases,  however,  stimulants  are  more  valuable  than  opium.  Extreme 
and  continuous  hyperpyrexia  should  be  treated  by  bathing  in  water  heated 
to  32°  C.  (90°  F.)  and  gradually  reduced  to  25.5°  C.  (80°  F.).  Excessive 
restlessness  is  to  be  treated  with  bromide  of  soda  in  doses  of  0.12  to 
0.6  gramme  (2  to  10  grains).  In  some  cases  subcutaneous  injections  of 
morphia,  beginning  with  0.0006  gramme  (y^^r  grain),  are  indicated. 

CHRONIC  INTESTINAL  INDIGESTION. 

In  both  types  of  intestinal  indigestion  the  acute  symptoms  may  pass 
off,  but  the  intestinal  disturbance  may  be  prolonged  for  weeks  and  even 


DISEASES   OF   THE   INTESTINE.  813 

months.  This  especially  occurs  in  children  whose  vitality  has  already 
been  lowered  and  whose  recuperative  power  has  been  lessened  by  some 
previous  disease,  such  as  rhachitis,  syphilis,  chronic  broncho-pneumonia, 
and  general  tuberculosis.  Improper  treatment  during  the  acute  attack  or 
the  continuous  administration  of  improper  food,  undue  exposure  from 
improper  clothing  and  bad  hygienic  surroundings  may  produce  this  con- 
dition. 

This  class  of  cases  is  a  very  large  one,  and  one  which  increases  greatly 
the  mortality,  especially  during  the  first  year  of  life. 

Pathological  Anatomy. — In  many  cases  the  post-mortem  shows  no 
demonstrable  lesions.  In  other  cases  various  types  of  ileo-colitis  have 
been  found.  Lesions  are  certainly  more  common  in  the  chronic  than  in 
the  acute  forms  of  intestinal  indigestion. 

It  has  not  yet  been  definitely  determined  whether  such  lesions  are  due 
to  the  prolonged  irritation  of  intestinal  indigestion  alone  or  whether  there 
may  not  have  been  an  infection  which  has  escaped  clinical  recognition. 

Prognosis. — If  this  chronic  condition  is  present  in  one  of  the  systemic 
diseases  just  mentioned  the  prognosis  is  bad  ;  if  it  follows  an  acute  attack 
occurring  in  a  previously  healthy  individual  it  is  serious  but  is  fairly  good 
if  properly  treated  and  not  subjected  to  long  and  continuous  spells  of  hot 
weather. 

Symptoms. — These  cases  are  characterized  by  their  chronic  course,  by 
the  irregularity  of  the  intestinal  discharges,  which  at  times  are  normal,  and 
present  when  abnormal  the  most  varied  appearances. 

As  a  rule,  these  infants  do  not  gain  in  weight  regularly  or  normahy  and 
usually  show  a  progressive  loss.  They  become  ansemic.  The  skin  is  apt 
to  be  dry.  The  temperature  may  from  time  to  time  show  a  slight  tem- 
porary elevation  but  is  usually  normal  or  subnormal.  The  infants  are 
fretful,  do  not  sleep  well  and  present  the  picture  of  moderate  and  some- 
times severe  malnutrition. 

Treatment. — The  treatment  of  chronic  intestinal  indigestion  is  usually 
difficult.  The  very  fact  that  such  a  condition  is  present  presupposes  that 
either  the  infant  has  been  or  is  suffering  from  some  unusually  serious  dis- 
ease and  that  in  spite  of  previous  treatment,  whether  by  diet  or  drugs,  there 
has  resulted  a  great  deterioration  of  the  patient's  recuperative  power.  If 
possible,  it  is  in  most  cases  wise  to  provide  good  human  breast-milk  at 
once.  Where  this  is  not  possible  or  fails  each  individual  should  be  studied 
and  treated  with  various  modifications  of  milk  according  to  its  especial 
need.  No  especial  percentag-es  of  the  individual  elements  of  the  milk  are 
known  to  suit  these  cases.  It  is  well  to  start  with  low  percentages  and  to 
try  various  combinations  of  these  percentages  following  the  general  indica- 
tions of  percentage  feeding.  It  is  often  found  that  whey  mixtures  are 
valuable  and  they  should  be  tried  first  before  using  the  whole  proteid. 
Peptonization  of  the  modified  milk  is  a  very  valuable  adjunct  in  many 
cases.     Complete  peptonization  is  usually  not  needed,  the  partial  pepto- 


814  PEDIATRICS. 

nization  by  adding  the  peptonizing  powder  to  the  food  when  it  is  being 
warmed  for  administration  often  being  sufficient.  Some  physicians  of 
experience  believe  that  milk  should  be  withheld  for  a  short  time,  sul^sti- 
tuting  in  its  place,  white  of  egg,  beef-juice,  or  barley-water  with  sugar 
added.  This  in  our  experience  is  seldom  successful  where  careful  and 
exact  modification  of  milk  has  failed. 

This  class  of  cases  is,  however,  so  difficult  to  control  that  a  variety  of 
treatments  which  includes  the  experience  of  many  physicians  should 
unhesitatingly  be  tried.  Although  in  certain  cases  the  employment  of  irriga- 
tion and  of  bismuth  is  required,  yet,  as  a  rule,  they  are  not  indicated.  In  a 
great  majority  of  cases  drugs  are  not  useful,  but  laxatives  are  occasionally 
necessary.  Fresh  air,  sun-light,  good  liygienic  surroundings  and  often 
change  of  climate  or  from  inland  districts  to  the  sea-shore  are  important 
factors  in  the  treatment. 

When  a  child  in  the  warm  weather  has  once  had  an  attack  of  fermental 
diarrhoea  it  "is  very  apt  to  have  a  number  of  attacks  if  it  is  not  guarded.  Its 
diet,  therefore,  should  be  carefuhy  regulated  for  a  considerable  period,  and 
if  possible  it  should  be  taken  to  the  sea-shore  or  the  country  until  the 
return  of  cool  weather. 

As  especial  illustrations  of  the  great  variety  of  fermental  diarrhoeas 
wliich  are  liable  to  be  met  with  in  warm  weather  the  follo\nng  cases  may 
be  taken  as  examples  : 

A  child  three  years  old  and  perfectly  well  was  attacked  suddenly  with  abdoudnal 
pain,  nausea,  pallor,  and  prostration.  He  vomited  once  or  twice  and  was  found  to 
have  a  temperature  of  40°  C.  (104°  F.).  Within  a  few  hours  he  began  to  have  fre- 
quent faecal  dejections  of  sour  odor,  lessened  consistency,  moderate  amount,  and  a 
peculiar  dark  green  color  (Plate  III.,  No.  18,  facing  page  77).  This  green  is  one  of 
the  more  common  colors  met  with  in  fermental  diarrhoea.  At  first  the  discharges  took 
place  every  hour,  and  later  every  three  or  four  hours.  After  the  first  twenty-four  hours 
the  temperature  became  normal  and  in  three  or  four  days  the  diarrhcea  ceased  entirely. 

The  next  case  was  that  of  an  infant  thirteen  months  old.  On  entering  the  hos- 
pital it  was  much  emaciated  and  had  a  slight  diarrhoea,  caused  apparently  by  improper 
food.  Its  temperature  was  only  slightly  raised.  On  examining  it  nothing  else  abnor- 
~nial  was  detected.  The  diarrhoea  was  infrequent  and  was  not  accompanied  by  any 
other  especial  symptoms.  It  soon  began  to  improve,  gained  in  weight,  and  had  a  nor- 
mal temperature.  After  it  had  been  in  the  hospital  one  week  it  suddenly  began  to 
have  diarrhoea  characterized  by  large  frequent  discharges  of  lessened  consistency,  of 
foul  odor,  and  of  the  color  which  is  seen  in  Plate  III.,  No.  19,  facing  page  77,  which 
is  a  mixture  of  yellow  and  light  and  dark  green.  The  discharge  seemed  from  its  foul 
odor  to  be  an  illustration  of  what  is  called  albuminous  decomposition.  These  colors 
are,  however,  only  relative  and  are  not  diagnostic.  In  this  acute  attack  the  tempera- 
ture was  raised  at  first  but  soon  fell  to  a  little  above  normal.  The  infant  lost  greatly  in 
weight,  became  extremely  emaciated,  and  looked  as  if  it  would  die.  The  skin  often 
became  cold,  and  the  prostration  Avas  extreme.  These  symptoms  continued  for  three 
or  four  days,  and  the  number  of  the  discharges  in  the  twenty-four  hours  varied  from 
seven  to  ten.  The  symptoms  gradually  became  less  severe  and  the  diarrhoea  abated. 
Later  the  diarrhoea  stopped  entirely,  and  the  infant  gained  rapidly  in  weight  and 
strength. 


DISEASES  OF  THE  INTESTINE.  815 

III.  Infectious. — By  infectious  diseases  of  the  intestine  we  mean  a 
condition  in  which  there  is  a  true  infection  of  the  tissues  by  bacteria. 
These  infections  may  produce  such  definite  diseases  as  jDroctitis,  appendi- 
citis and  fistulEe  or  that  large  class  of  diarrhoeal  diseases  which  constitute 
the  most  important  and  serious  conditions  affecting  the  gastro-enteric  tract. 

As  the  source  of  infection  in  this  latter  class  varies  greatly  and  as  there 
is  neither  a  definite  morbid  anatomy,  or  a  constant  symptomatology  corre- 
sponding to  the  infection  by  a  special  organism,  we  use  for  the  present  the 
name  of  the  constant  and  most  prominent  symptom,  diarrhoea,  and  speak 
of  this  group  of  intestinal  diseases  as  infectious  diarrhoea. 

INFECTIOUS  DIARRHCEA. 

Pathological  Anatomy. — The  great  number  of  lymph-nodules  and  the 
abundance  of  the  lymphatic  plexuses  are  the  principal  anatomical  condi- 
tions which  influence  the  pathology  of  the  enteric  tract  in  early  life. 

The  general  pathological  anatomy  of  the  gastro-enteric  tract  of  infancy 
and  early  childhood  is  essentially  that  of  the  ileum  and  colon.  In  those 
cases  in  which  the  more  severe  lesions  are  present  the  stress  of  the  lesion 
is  usually  in  the  lower  ileum  and  the  colon,  and  very  frequently  in  the 
colon  only.  For  this  reason  the  terms  ileo-colitis  and  colitis  seem  more 
descriptive  than  ileo-enteritis  and  enteritis.  The  pseudo-membrane  is  often 
extensive,  but  sloughing  and  perforation  are  exceedingly  rare  in  young 
children.  The  lesions  in  infectious  diarrhoea  are  sometimes  imperceptible 
to  the  naked  eye  or  they  may  represent  all  forms  of  ileo-colitis  whether 
catarrhal,  ulcerative,  or  membranous.  Every  degree  of  these  lesions  may, 
so  far  as  we  can  determine,  arise  from  any  one  or  any  group  of  the  known 
infecting  organisms.  Any  one  of  them  may  cause  violent  and  serious 
symptoms  without  a  corresponding,  severity  of  the  lesions.  Serious  lesions 
may  be  present  and  yet  the  symptoms  may  not  be  correspondingly  severe. 
Marked  diarrhoea  may  exist  during  life  and  no  lesions  be  present  at  the 
autopsy.  Serious  lesions  may  exist  and  yet  no  blood  appear  in  the  dejec- 
tions. Blood  may  appear  in  the  dejections,  and  yet  no  serious  lesion 
exist,  the  hemorrhage  being  only  temporary,  and  comparable  to  epistaxis. 
The  intestinal  discharges  are,  therefore,  often  very  misleading. 

The  following  plates  illustrate  certain  lesions  which  have  been  found  in 
cases  of  infectious  diarrhoea. 

The  clinical  histories  of  these  cases  were  very  imperfect.  The  necessary 
data  for  diagnosis  being  often  omitted.  In  general,  they  were  compatible 
with  the  description  of  infectious  diarrhoea,  but  in  many  instances  showed 
a  remarkable  lack  of  correspondence  with  the  post-mortem  findings. 

The  first  specimen  (Fig.  165)  is  a  portion  of  the  colon  of  an  infant 
which  shows  hyperplasia  of  the  lymph-follicles. 

The  lesion  is  quite  marked  and  simulates  closely  the  hyperplasia  of 
Peyer's  patches  which  is  commonly  seen  in  typhoid  fever. 

The  next  specimen  (Fig.  166)  was  found  at  the  autopsy  of  a  little  girl, 
three  years  old. 


816  PEDIATRICS. 

The  lesions  were  chiefly  in  the  upper  part  of  the  colon,  and  consisted  of  a  general 
non-ulcerative  follicular  inflammation.  The  hyperplasia  of  Peyer's  patches  was 
extreme. 

The  following  interesting  specimens  of  lesions  of  colitis  occurred  in  the 
hospital  service  of  Dr.  Northrup,  and  are  now  preserved  in  the  Museum 
of  the  College  of  Physicians  and  Surgeons,  New  York. 

Fig.  167  shows  an  acute  catarrhal  follicular  inflammation  without 
ulceration. 

The  small  intestine  contained  a  large  amount  of  thiclc  mucus.  The  solitary  folli- 
cles were  enlarged,  rather  more  in  the  upper  third  of  the  intestine.  Peyer's  patches 
were  markedly  swollen,  and  a  few  solitary  follicles  appeared  to  he  ulcerated.  The 
mesenteric  lymph-glands  were  enlarged.  The  mucous  membrane  of  the  colon  was 
swollen  ;  the  follicles  were  enlarged  and  somewhat  pigmented,  but  not  ulcerated. 

Fig.  165. 


Hyperplasia  of  the  lymph-follicles.    Warren  Museum,  Harvard  University. 


Fig.  168  shows  another  portion  of  the  colon  taken  from  the  same  infant. 

The  solitary  follicles  are  very  much  enlarged,  and  in  Peyer's  patches, 
Avhich  are  in  the  middle  of  the  specimen,  the  hyperplasia  is  of  a  very 
high  degree. 

Figs.  169  and  170  illustrate  microscopic  sections  of  this  form  of 
follicular  inflammation.  The  former  showed  the  great  enlargement  of 
the  lymph-follicles  ;  the  latter  showed  the  inflamed  condition  of  the 
mucous  membrane  as  well  as  the  enlarged  lymph-follicles. 

The  next  specimen  (Fig.  171)  was  taken  from  an  infant,  sixteen 
months  old. 

The  autopsy,  made  by  Northrup,  gave  the  following  results  :  small  intestine  showed 
much  swelling  and  congestion  of  Peyer's  patches,  but  no  ulceration.  The  colon  showed 
extensive  follicular  ulcerations.  In  the  small  intestine  and  the  colon  were  found  masses 
of  strings  of  greenish  mucus  ;  no  blood. 

The  next  specimen  (Fig.  172)  was  taken  from  a  female  infant,  three 
months  old. 


Fig.  166. 


Non-ulcerative  follicular  inflammation.    Simple  hyperplasia  of  lymph-foUieles. 
Female,  3  years  old.    Warren  Museum,  Harvard  University.    (Page  815.) 


Fig.  Ifi 


CJolitis  follicularis  non-ulcerativa.    Male,  2  years  old.    Museum  of  the  College  of  Physicians 
and  Surgeons,  New  York.    (Page  816.) 


Pig.  168. 


Colitis  foUieularis  non-uleerativa.     i  I'a.w  Mo., 


Fig.  169. 


Hyperplasia  of  lympli-follicles  (solitary  glands).     Muc.  Mem.,  mucous  meml:)rane  ;  Lym.  Ts., 
lymph-tissues;  Mus.,  muscle;  Fol.,  follicles.    (Page  816.) 


Fig.  170. 


Muo.  Mem.,  mucous  membrane  :  Fol.,  Tollicles  ;  Submuc,  submucous  tissue  ;  Mus.,  muscle. 

(Page  816. ) 


Fig.  171. 


neo-colitis  ulcerativa  follicularis.    Infant,  16  months  old.    Museum  of  the  College  of  Physicians 
and  Surgeons,  New  York.    (Page  816.) 


Fig.  172. 


Acute  ulcerative  catarrhal  colitis.    Female,  3  months  old.    Museum  of  the  College  of  Physicians 
and  Surgeons,  New  York.    (Page  816. ) 


Fig.  173. 


Inflammation  of  follicles  and  surrounding  parts  of  colon.    The  process  has  gone  on  to  necrosis.    Female, 
3  months  old.    Warren  Museum,  Harvard  University.     (Page  817.) 


Pigmented  follicular  ulcers  of  colon.    Chronic  catarrhal  ulcerative  follicular  colitis.    Museum  of  the 
College  of  Physicians  and  Surgeons,  New  York.    (Page  817. ) 


Fig.  175. 


Pseudo-membranous  colitL..    Child,  3%  yeai^  old.    Museum  of  the  College  of  Physicians  and 
Surgeons,  New  York.    (Page  81/.) 


Ftc.  176. 


Pseudo-membranous  colitis.    Female,  4  years  old.    Ps.  M.,  pseudo-membrane  ;  M.  M.,  mucous 
membrane;  Subm.,  submucosa;  Mus.,  muscle;  Per.,  peritoneum.    (Page  817.) 


Fig.  17^ 


Nee  Mlic  Mem 


Inf  Muc  Mem 


Mus 
Submuc  / 


Nee.  Muc.  Mem.,  necrotic  mucous  memljraiie  ;  luf.  Muc.  Mem.,  inflamed  mucous  membrane  ; 
Mus.,  m.uscle;  Submuc,  submucosa.    (Page  817.) 


DISEASES   OF   THE   IXTESTINE.  817 

The  autopsy  was  made  by  Xorthrup.  and  showed  the  following  lesions  :  the  mucous 
membrane  of  the  ileum  was  swollen,  and  the  lymph-follicles  were  enlarged,  but  not 
ulcerated.  The  report  of  the  examination  of  the  colon  was  as  follows:  numerous 
ulcers,  some  round  and  some  irregular  in  shape  ;  an  increased  production  of  mucus  ; 
a  profuse  growth  of  connective  tissue  between  the  tubules,  with  disappearance  of  the 
tubules  ;  necrosis  of  the  new  tissue  so  as  to  form  ulcers  ;  the  solitary  follicles  swollen, 
but  not  concerned  in  the  formation  of  ulcers,  which  were  simply  necrotic.  Xo  amoebae 
found.  The  process  was  one  which  would  ordinarily  come  under  the  head  of  acute 
catarrhal  colitis. 

The  next  specimen  (Fig.  173)  was  taken  from  an  infant,  three  months 
old,  in  the  hospital  under  the  care  of  Dr.  Holt. 

The  post-mortem  examination  showed  extensive  follicular  ulcerations  of  the  colon, 
especially  in  the  lower  part  of  the  specimen,  where  there  was  a  large  ulcer.     The  tissues 

around  the  follicles  are  also  involved,  and  the  process  had  gone  on  to  necrosis. 

The  next  specimen  fFig.l74')\vas  taken  from  a  male  infant  six  months  old. 

The  autopsy,  made  by  Xorthrup,  showed  numerous  superficial  abscesses  on  the 
body,  a  general  bronchitis,  and  a  beginning  broncho-pneumonia.  The  lesions  in  the 
intestine  were  an  inflammation  of  the  solitary  foUicles  of  the  ileum  and  of  the  colon, 
with  small  ulcerations  at  the  apices  of  the  follicles  in  the  colon,  no  ulcers  being  present 
in  the  ileum.  In  the  specimen  the  ulcers  were  pigmented,  which  denoted  a  chronic 
condition.  The  apices  of  the  follicles  are  sometimes  found  pigmented  as  the  result  of 
post-mortem  changes,  and  may  simulate  these  ulcerations. 

The  next  specimen  (Fi,2'.  175)  was  one  of  pseudo-membranous  colitis. 

The  autopsy  showed  a  pseudo-membranous  inflammation  through  the  whole 
length  of  the  colon,  most  marked  in  the  lower  third.  The  microscopic  examination  of 
the  colon  confirmed  the  diagnosis  of  pseudo-membranous  colitis. 

Fig.  176  shows  a  microscopic  section  of  another  case  of  pseudo-mem- 
branous colitis. 

The  autopsy  showed  that  the  mesenteric  lymph-follicles  were  not  much  enlarged ; 
the  follicles  in  the  colon  were  slightly  enlarged.  The  whole  intestine  was  injected  in 
patches,  and  contained  fascal  masses  of  a  yellowish  color.  The  large  intestine  was 
filled  with  large  quantities  of  fseces  of  foul  odor  and  colored  by  bismuth.  The  whole 
surface  was  rough,  and  did  not  look  like  a  mucous  membrane,  but  rather  as  though  a 
thin  layer  of  gelatin  had  been  poured  over  it.  This  film  could  be  pulled  away  with 
the  forceps.  The  solitary  follicles  were  enlarged.  The  microscopic  section  of  this 
specimen  showed  a  marked  fibrino-purulent  exudation,  forming  a  membrane  which 
characterized  the  disease  as  pseudo-membranous  colitis. 

In  connection  with  the  pseudo-membranous  condition  shown  in  Fig. 
175.  another  specimen  (Fig.  177)  is  of  interest. 

The  colon  showed  an  apparent  exudation,  which  simulated  that  of  a  pseudo- 
membranous colitis  so  closely  that  before  the  microscopic  examination  was  made  it  was 
supposed  to  be  identical  with  the  pathological  lesions  found  in  the  case  of  pseudo- 
membranous colitis  (Fig.  175).  The  surface  appeai-ance  in  the  fresh  specimen  was 
identical.  Under  the  microscope,  however,  the  lesion  proved  to  be  only  a  superficial 
necrosis  of  the  mucosa,  with  swelling  of  the  Ivmph-follicles. 

52" 


818  PEDIATRICS. 

Etiology. — The  cause  of  infectious  diarrhoea  is  now  recognized  to  be 
from  an  infection  of  the  tissues  hy  specific  organisms  or  groups  of  organ- 
isms. Mixed  infection  is  common.  The  infecting  organisms  are  deter- 
mined to  he  causative  by  examination  of  the  faecal  discharges,  by  aggluti- 
nation reactions  in  the  blood  of  the  patient,  and  by  examination  of  the 
tissues  post  mortem.  It  is  now  believed  to  be  highly  probable  that  patho- 
genic organisms  maybe  present  in  the  intestine  without  necessarily  infect- 
ing the  individual,  "and,  as  in  non-infectious  cases,  lead  a  saprophytic 
existence  until  the  intestine  becomes  vulnerable. 

Although  a  number  of  pathogenic  organisms,  such  as  the  bacillus  pyo- 
cyaneus  and  the  streptococcus  pyogenes,  have  been  proved  to  be  the  cause 
of  certain  cases  of  infectious  diarrhoea,  yet,  in  the  great  majority  of  cases 
so  far  reported,  the  etiologic  factor  of  the  acute  infectious  charrhoeas  is  the 
different  types  of  the  bacillus  dysenterise  of  Shiga  and  Flexner. 

Although  these  infections  occur  most  commonly  in  hot  weather,  yet 
they  are  met  with  at  all  times  of  the  year,  so  that  the  term  "  summer 
diarrhoea"  is  misleading  and  should  not  be  used,  while  the  term  dysentery 
should  only  be  applied  to  those  cases  in  which  the  infection  is  from  the 
bacillus  dysenteriae.  The  bacillus  dysenterise  in  its  different  types  is  the 
cause  of  both  epidemic  and  endemic  dysentery.  The  form  which  is 
caused  by  the  amoeba  coli  is  not  common  in  children  ;  it  is  described  as  a 
specific  disease  on  page  494.  The  various  etiologic  factors  previously 
spoken  of  in  connection  with  the  non-infectious  cases  on  page  807  are 
also  factors  in  the  infectious  cases,  infected  milk  and  thermic  conditions 
being  especially  prominent  as  predisposing  causes.  Infection  may  take 
place  primarily  with  acute  onset.  The  infection  may  be  secondary  to  in- 
fectious diseases  such  as  the  exanthemata,  diphtheria,  broncho-pneumonia, 
and  any  conditions  which  increase  the  general  susceptibility. 

In  a  large  number  of  cases  the  infection  follows  one  of  the  functional 

disturbances  already  described.      When  the  irritation    caused  by  these 

disturbances  is  sufficient  to  render  the  intestine  vulnerable,  the  specific 

infection  takes  place  with  shght  or  severe  symptoms,  according  to  the 

^virulence  of  the  organism,  or  to  the  idiosyncrasy  of  the  individual. 

Symptoms. — The  symptoms  of  the  various  forms  of  infectious  diarrhoea 
vary  greatly,  but  in  a  general  way  this  class  of  diarrhoeas  can  often  be 
recognized  by  a  group  of  symptoms  which  differ  from  that  of  the  non- 
infectious diarrhoeas.  The  symptoms,  however,  of  these  different  forms 
of  infectious  diarrhoea  are  very  unsatisfactory  and  unreliable  for  differ- 
ential diagnosis. 

The  onset  of  the  disease  may  be  preceded  by  the  symptoms  of  one  of 
the  non-infectious  forms,  or  it  may  be  acute  from  the  beginning  and  have 
prodromal  symptoms  of  no  more  than  a  few  hour?.  The  temperature  is 
elevated,  the  pulse  is  accelerated,  and  the  infant  loses  rapidly  in  weight 
and  strength.  There  may  be  vomiting,  which  is  often  notably  severe 
during  the  period  of  onset.     The  discharges  are  perhaps  ten  or  twenty,  or 


DISEASES   OF   THE   INTESTINE.  819 

even  more,  in  the  twenty-four  hours,  but  are  comparatively  small  in 
amount.  When  there  is  much  irritation  in  the  rectum  there  is  tenesmus 
both  before  and  after  the  discharge,  and  in  the  beginning  of  the  attack  an 
almost  constant  desire  to  have  a  movement.  The  discharges  contain  faecal 
matter  at  first,  but  soon  become  small,  and  consist  of  mucus,  sometimes 
with  pus,  blood,  and  shreds  of  membrane.  The  odor  may  be  very  offen- 
sive, but  when  the  mucus  predominates  there  is  very  little  odor.  The 
color  and  consistency  are  extremely  variable,  but  generally  the  consistency 
is  lessened  and  the  color  is  a  mixture  of  green,  brown,  and  yellow.  The 
blood  is  usually  from  congestion  of  the  blood-vessels  and  straining,  rather 
than  from  ulceration,  so  that  we  cannot  determine  from  the  presence  of 
blood  whether  ulceration  is  present  or  not.  At  first  the  abdomen  may  be 
soft  and  not  tender,  but  later  it  becomes  distended,  tympanitic,  and  some- 
what tender,  especially  along  the  course  of  the  colon.  Vomiting  may 
occur  at  times.  In  severe  cases  the  child  is  very  restless,  and  there  may 
be  delirium  and  convulsions.  The  appetite  is  usually  much  lessened. 
The  urine  is  nearly  always  diminished  in  quantity,  is  high-colored,  and 
sometimes  contains  a  small  amount  of  albumin,  especially  when  the 
temperature  is  high.  Casts  may  also  be  found.  The  renal  condition  in 
these  cases  is  a  degenerative  one,  and  not  a  true  nephritis.  Acute 
glomerular  nephritis  is  rare.  When  there  is  much  tenesmus  and  straining, 
and  when  the  discharges  are  especially  frec[uent,  prolapse  of  the  rectum 
may  occur.  The  discharges  often  cause  great  irritation  around  the  anus 
and  on  the  buttocks. 

It  is  usually  found  in  the  simple  catarrhal  ileo-colitis,  when  ulceration 
has  not  taken  place,  that  the  symptoms  are  milder  and  that  there  is  apt 
to  be  vomiting.  The  cases  generally  begin  to  improve  in  one  or  two 
weeks,  and  recover  entirely  in  another  week.  The  children  are  usually 
a  long  time  in  regaining  their  strength,  and  relapses  are  quite  common  in 
this  form  if  the  diet  is  not  carefully  regulated.  Sometimes,  however, 
simple  catarrhal  ileo- colitis  may  be  represented  by  symptoms  of  a  very 
severe  type  and  prove  rapidly  fatal. 

When  follicular  ulceration  has  taken  place  the  stomach  is  not  apt  to 
be  much  involved,  the  temperature  is  not,  as  a  rule,  high,  and  the  course 
of  the  disease  is  rather  slow,  irregular,  and  prolonged.  The  infant  fails 
steadily  and  commonly  dies.  When  the  inflammation  is  simply  follicular, 
without  ulceration,  the  cases  are  very  apt  to  recover. 

Pseudo-membranous  ileo-colitis  is  rare  in  infants,  but  when  it  occurs 
it  is  the  most  severe  of  all  the  forms.  The  temperature  is  high, — 39.4°, 
40°,  or  40.5°  C.  (103°,  104°,  or  105°  F.).  There  are  apt  to  be  blood  and 
membranous  detritus  in  the  discharges.  The  progress  of  the  disease  is 
usually  rapid  and  without  remission,  and  death  may  take  place  in  a  week 
or  ten  days.  Nervous  symptoms,  such  as  restlessness  and  delirium,  are 
quite  prominent. 

Dunn's  critical  study  of  620  consecutive  cases  of  diarrhoea  during  his 


820  PEDIATRICS. 

service  in  July,  August,  and  September,  1903  and  1904,  at  the  Thomas 
Morgan  Rotch,  Jr.,  Memorial  Hospital  for  Infants,  gives  a  careful  analysis  of 
this  class  of  cases.  Dunn's  observations  show  that  blood  may  occur  in  the 
non-infectious  types  of  diarrhcea  represented  by  indigestion,  but  that  it  is 
more  apt  to  occur  in  the  infectious  type  in  the  proportion  of  4  to  1,  Out 
of  the  total  620  cases  111  were  of  the  infectious  type,  and  of  these  111 
cases  42  per  cent,  showed  blood  in  the  movements,  Avhile  of  the  remaining 
509  cases,  which  were  of  the  non-infectious  type,  only  10.5  per  cent, 
showed  blood  in  the  movements.  Moreover,  in  nearly  all  the  cases  of  the 
infectious  type  the  blood  appeared  early  in  the  course  of  the  disease ; 
whereas  in  the  non-infectious  types  the  blood  appeared  after  a  more  or 
less  prolonged  course  of  diarrhoea.  Also,  when  the  blood  appeared  in 
marked  excess,  the  cases  were  clinically  always  of  the  infectious  type. 
Out  of  47  cases  in  which  more  blood  than  mere  specks  was  present  60  per 
cent,  were  of  the  infectious  type.  The  most  severe  and  fatal  toxaemia 
may  develop  without  blood  appearing  in  the  movements.  The  diarrhoea 
varies  in  severity,  the  variations  bearing  no  definite  relation  to  the  severity 
of  the  case. 

It  was  noticed  that  in  most  of  the  cases  in  which  mucus  was  noted  in 
marked  excess  in  the  movements,  the  cases  were  of  the  infectious  type. 
The  presence  of  mucus  seems  to  be  a  usual  symptom  of  this  type.  Out 
of  the  111  cases,  mucus  occurred  in  86,  or  78  per  cent.  In  the  remaining 
509  non-infectious  cases,  mucus  was  noted  in  258,  or  about  50  per  cent. 

All  the  cases  in  which  the  movements  contained  only  blood  and 
mucus,  or  mucus  alone,  30  in  number,  were  febrile  cases. 

Colic  was  often  present  and  often  absent  in  all  types.  Loss  of  weight 
was  notably  rapid  in  all  infectious  cases  that  remained  under  observation, 
and  was  never  noted  as  absent.  Vomiting  was  present  and  absent  in  all 
types,  but  present  in  68  per  cent,  of  the  infectious  type,  and  in  47  per 
cent,  of  the  other  types. 

Of  the  111  infectious  cases  all  were  febrile,  and  of  these  cases  84  were 
"primary";  that  is,  showed  fever  and  constitutional  symptoms  at  the 
/^'"Beginning  of  the  diarrhoea ;  27  developed  febrile  and  constitutional  symp- 
toms sulDsequently  to  a  period  of  indigestion. 

Great  variations  are  observed  in  the  severity  of  the  infectious  cases. 
In  all  cases  the  onset  of  fever  is  abrupt.  In  most  cases  it  accompanies 
the  diarrhosa.  In  some  it  precedes  the  diarrhoea  by  twelve  to  twenty-four 
hours.  In  others  it  fohows  upon  a  period  of  a  febrile  intestinal  disturb- 
ance. When  fever  is  present  there  are  usually  constitutional  symptoms, 
and  more  marked  prostration  than  in  the  cases  having  diarrhoea  of  equal 
severity,  but  without  fever.  The  fever  may  be  moderate,  and  of  short 
duration,  and  the  child  make  a  very  rapid  recovery  under  treatment,  or 
there  may  be  high  fever,  marked  prostration,  and  a  rapidly  fatal'ending. 

Diagnosis. — Although  the  detection  of  specific  causative  organisms  by 
their  cultural  characteristics  and  agglutination  reactions  is  the  only  certain 


DISEASES   OF  THE   INTESTINE.  821 

means  of  diagnosis,  it  can  be  said  that  clinically  an  excess  of  mucus  in  the 
movements,  with  the  early  appearance  of  blood  and  a  continued  height- 
ened temperature,  are  the  special  characteristics  differentiating  the  in- 
fectious diarrhoeas  from  the  non-infectious.  From  cholera  infantum  the 
other  infectious  diarrhoeas  can  be  differentiated  by  not  showing  the 
continuous  and  excessive  vomiting  and  serous  discharges  of  the  former 
disease. 

Prognosis. — While  the  prognosis  in  all  types  of  diarrhoea  when  properly 
treated  is  favorable  in  most  cases,  excepting  in  epidemics  of  unusual 
severity,  yet,  as  is  shown  in  the  following  table,  rapid  recovery  and  fewer 
deaths  occur  in  the  non-infectious  than  in  the  infectious  cases  : 

TABLE  70.      [Dunn.] 

Non-infectious.  Infectious. 

Rapid  recovery 50%  S8 fo 

Gradual  recovery  or  improvement  only 12  fo  30% 

No  improvement 2%  12% 

Death ^^fo  6% 

The  prognosis,  when  ulceration  has  not  occurred,  is  usually  favorable, 
the  duration  of  the  disease  being  a  few  weeks.  Some  cases,  however,  are 
more  severe,  and  sometimes  prove  fatal  in  a  few  days.  When  there  is 
ulceration,  the  prognosis  is  rather  unfavorable.  When  there  is  a  diminu- 
tion in  the  frequency  of  the  discharges  and  fascal  matter  begins  to  reappear, 
and  when  the  nervous  symptoms  and  exhaustion  lessen,  the  prognosis  is 
good ;  but  when  the  symptoms  increase  in  severity  and  the  face  looks 
pinched,  when  intractable  vomiting  arises  and  the  nervous  symptoms 
predominate,  the  prognosis  is  very  unfavorable. 

The  prognosis  is  less  favorable  when  the  disease  is  complicated  by 
broncho-pneumonia  or  tuberculosis.  It  is  much  influenced  by  the  time 
of  the  year  at  which  the  attack  takes  place,  the  prognosis  being  worse  if 
the  disease  occurs  at  a  time  when  the  convalescence  is  during  a  long 
heated  period.  The  prognosis  is  also  worse  when  the  infants  have  to  be 
treated  in  crowded  cities  and  in  the  midst  of  unsanitary  surroundings. 

Prophylaxis  and  Treatment. — The  treatment  of  these  forms  of  infec- 
tious diarrhoea  should  usually  in  the  beginning  be  the  same  as  has  already 
been  described  for  non-infectious  diarrhoea,  and  may  in  this  sense  be  spoken 
of  as  prophylactic.  When  the  case  is  seen  in  its  earlier  stages,  a  mild 
laxative  should  be  given,  in  order  to  clear  away,  so  far  as  possible,  the 
pathogenic  organisms,  which  are  present  in  large  numbers.  Small  doses 
of  castor  oil  act  most  efficiently,  and  can  usually  be  given,  especially  to 
infants,  without  causing  nausea  or  gastric  irritation. 

In  addition  to  this  treatment  by  the  mouth,  thorough  irrigation  of  the 
colon  should  be  employed.  This  should  be  done  twice  in  the  twenty- 
four  hours  with  warm  sterilized  water  containing  3.75  grammes  (1  drachm) 
of  borate  of  sodium  to  the  pint  of  water.     Two  to  four  quarts  of  water 


822  PEDIATRICS. 

should  be  allowed  to  flow  in  and  out  of  the  intestine  at  each  irrigation. 
After  the  irrigation,  small  enemata  of  thin  mucilage,  about  120  c.c.  (4 
ounces),  containing  15  grammes  (^  ounce)  of  bismuth  in  suspension,  may 
be  given  once  in  three  or  four  hours. 

According  to  the  degree  of  pain,  restlessness,  and  general  discomfort, 
a  slight  amount  of  opium  can  be  given  in  these  injections,  but  in  all 
cases  this  drug  should  be  administered  with  great  care ;  0.03  c.c.  (| 
minim)  of  tincture  of  opium  in  the  first  year,  and  0.06  c.c.  (1  minim)  in 
the  second  year,  once  in  five  or  six  hours,  will  usually  be  sufficient  to 
make  the  infant  comfortable.  The  effect  of  the  opium  should  be  carefully 
watched,  and  the  dose  increased  or  decreased  as  is  necessary. 

When  the  tenesmus  is  extreme,  it  is  well  to  use  suppositories  con- 
taining from  0.015  to  0.03  gramme  (|  to  J  grain)  of  cocaine.  These 
suppositories  will  often  give  great  relief  if  the  painful  lesions  are  mostly 
in  the  rectum,  but  when  the  lesions  are  higher  in  the  colon  they  are  not 
of  much  value,  and  when  the  tenesmus  is  continuous  and  exhausting, 
and  the  suppositories  ineffective,  a  subcutaneous  injection  of  morphia, 
0.003  gramme  (^V  grain),  Avith  atropia,  0.0003  gramme  (^J-o  grain),  can 
be  given. 

The  use  of  antiseptics  by  the  mouth  we  do  not  recommend.  Bismuth 
can  be  given  by  the  mouth  with  some  advantage  in  these  cases,  but  the 
dose  must  be  considerable  to  accomplish  good  results.  1.87  gramme  (| 
drachm)  in  the  twenty-four  hours  should  be  given  to  a  child  a  year  old, 
and  for  older  children  the  dose  should  be  proportionately  increased. 
Brandy  can  be  given  with  benefit  at  all  stages  of  the  disease  if  there  is 
evidence  of  a  weakened  heart,  or  if  much  exhaustion  is  present. 

A  very  limited  amount  of  food  of  any  kind  should  be  given  during 
the  first  twenty-four  hours.  Sterilized  water  containing  brandy  and  barley- 
water  had  better  be  given  at  first,  as  it  has  been  found  that  when  a  sterile 
liquid  is  taken  by  the  mouth  the  number  of  bacteria  in  the  intestine  dimin- 
ishes rapidly.  After  this  preliminary  treatment  if  a  perfectly  fresh  milk 
can  be  obtained  it  may  be  used,  if  sterilized  and  modified  in  its  various 
elements  so  as  to  be  adapted  to  the  digestion  of  the  especial  case.  A  low 
percentage  of  fat  and  sugar,  such  as  2  and  5,  and  a  proteid  percentage 
of  about  0.50,  is  a  very  good  prescription  to  begin  with.  It  should  be 
gradually  increased  by  the  addition  of  whey  until  the  full  amount  of 
diluent  is  whey,  then  the  fat  and  casein  should  be  by  degrees  increased. 
Weak  broths  can  also  be  given  to  older  children. 

Chronic  Infectious  Diarrhoea. — Etiology. — In  some  cases  of  infectious 
diarrhcea,  after  the  acute  symptoms  have  ceased,  the  diarrhoea  continues 
for  many  months,  and  the  disease  becomes  chronic. 

Pathological  Anatomy. — The  pathological  conditions  most  commonly 
found  in  these  chronic  forms  are  great  thickening  of  the  muscular  tissue, 
pigmentation  of  the  mucous  membrane,  and  very  extensive  ulceration. 

Symptoms, — There  is  no  especial  pain  or  tenderness,  and  the  tempera- 


DISEASES   OF   THE   INTESTINE.  823 

ture  may  be  normal.  The  appetite  often  returns,  but  the  child  does  not 
gain  in  weight,  or  it  loses.  The  discharges  are  not  so  frequent  as  ^uring 
the  acute  stage  of  the  disease,  varying  from  six  or  eight  to  two  or  three  in 
the  twenty-four  hours.  The  discharges  have  a  lessened  consistency,  and 
contain  mucus  and  undigested  food.  There  may  at  times  be  exacerba- 
tions of  the  symptoms,  and  the  children  are  very  apt  to  die  of  some 
intercurrent  disease.     The  duration  may  be  many  months. 

Treatment. — The  treatment  is,  if  possil^le,  a  change  of  air,  and  is 
otherwise  essentiahy  dietetic. 

The  rules  already  given  for  the  treatment  of  the  chronic  forms  of 
the  non-infectious  diarrhoeas  are  also  applicable  to  this  class  of  cases. 

CHOLERA    INFANTUM. 

One  form  of  infectious  diarrhoea  has,  from  its  intense  choleriform 
symptoms,  been  called  cholera  infantum.  The  term  cholera  infantum 
should  be  exclusively  restricted  to  this  class  of  cases,  and  should  not  be 
used  to  designate  the  many  acute  and  serious  attacks  of  vomiting  and 
diarrhoea  which  are  so  often  spoken  of  under  this  name.  It  is  a  rare 
disease  in  New  England,  although  the  name  often  wrongly  appears  in  the 
mortality  statistics. 

Etiology. — The  disease  is  probably  caused  by  a  specific  organism, 
but  this  has  not  yet  been  determined.  The  disease  occurs  in  the  first 
two  years  of  life,  and  in  its  development  is  probably  closely  associated 
with  the  food,  for  it  has  been  noticed  that  infants  who  are  fed  exclu- 
sively on  pure  and  sterile  foods,  such  as  breast-milk,  are  not  liable  to 
be  attacked  by  it.  It  is  also  significant  that  the  disease  occurs  only  in  hot 
weather. 

Pathological  Anatomy. — The  pathology  of  cholera  infantum  has  not 
yet  been  satisfactorily  determined,  but  it  seems  to  be  a  non-inflammatory 
disturbance  of  the  Avhole  gastro-enteric  tract,  without  any  gross  lesion 
beyond  a  desquamative  catarrh,  and  sometimes  hyperEemia  of  the  mucous 
membrane. 

Symptoms. — The  onset  of  cholera  infantum  may  be  sudden,  but,  as  a 
rule,  it  is  preceded  by  some  form  of  gastro-enteric  disturbance,  which,  by 
causing  an  irritation  of  the  mucous  membrane,  renders  the  infant  vul- 
nerable. When,  however,  the  disease  has  once  gained  a  foothold,  the 
development  of  the  symptoms  is  very  rapid. 

After  a  variable  but  generally  short  period  of  restlessness  and  ap- 
parent abdominal  discomfort,  the  infant  begins  to  vomit.  The  vomiting 
is  either  accompanied  or  quickly  followed  by  profuse  diarrhoea.  After  the 
stomach  and  intestine  have  been  emptied  of  the  food  which  may  happen 
to  be  in  them  at  the  time  of  the  onset,  the  vomitus  and  the  diarrhoeal 
discharges  are  chiefly  serous  ;  and  it  is  this  watery  consistency  of  the 
discharges  which  especially  characterizes  the  disease.     As  a  rule,  the  dis- 


824  PEDIATRICS. 

charges  are  odorless,  and  consist  of  serum  mixed  with  epithehal  cells  and 
many  bacteria.  Although  the  disease  is  more  likely  to  attack  weak  and 
debilitated  infants,  yet  it  often  attacks  those  who  are  healthy  and  robust. 
It  may  run  its  course  to  a  fatal  issue  in  from  twenty-four  to  forty-eight 
hours.  The  extremities  soon  become  cold,  the  skin  is  pallid  or  even 
cyanotic,  and  the  face  pinched.  The  abdomen  may  be  a  little  distended, 
but  is  soft,  and  soon  becomes  rather  retracted.  The  pulse  is  rapid  and 
difficult,  to  count.  Tlie  respirations  are  somewhat  quick  and  superficial. 
The  temperature  of  the  entire  surface  of  the  body  is  low,  but  the  deep 
rectal  temperature  is  high,  39.4°,  40°,  or  40.5°  C.  (103°,  104°,  or  105° 
F.).  The  thirst  is  great  and  is  a  very  prominent  symptom.  The  fonta- 
nelle  very  soon  becomes  depressed.  The  urine  is  very  scanty  and 
sometimes  suppressed.  It  is  concentrated,  highly  acid,  almost  always 
contains  albumin,  and  often  casts  and  blood.  Nervous  symptoms,  such  as 
twitching  of  the  arms  and  great  restlesness,  are  present.  Rapid  emaci- 
ation takes  place,  and  all  the  symptoms  increase  in  severity.  At  first  the 
infant  whimpers,  but  soon  it  becomes  listless,  falls  into  a  stupor,  or  may 
have  convulsions.  The  infant  may  die  in  this  stage,  which  closely  re- 
sembles the  algid  stage  of  cholera  Asiatica.  The  disease  appears  to  be 
self-limited,  and  if  the  infant  survives  the  first  two  or  three  days  a  crisis 
comes,  the  skin  becomes  less  cool  and  of  a  better  color,  the  vomiting  and 
diarrhoea  grow  less  frequent,  and  finally  it  is  left  with  a  slight  amount  of 
simple  diarrhoea  and  occasional  vomiting.  These  symptoms  may  become 
chronic,  in  which  case  the  infant  finally  dies  of  exhaustion  or  from  an 
attack  of  one  of  the  other  gastro-enteric  diseases,  to  which  it  is  left  very 
susceptible. 

Diagnosis. — The  diagnosis  of  cholera  infantum  is  not  difficult  if  the 
characteristic  symptoms  are  borne  in  mind  ;  these  are  rapid  onset,  con- 
stant vomiting,  frequent  serous  discharges,  intense  thirst,  high  rectal 
temperature,  low  surface  temperature,  collapse,  depressed  fontanelle, 
sudden  loss  of  weight,  and  distressed,  restless  expression,  suggesting 
speedy  death,  all   developing   in  from  twenty-four  to  forty-eight  hours. 

Prognosis. — The  prognosis  is  bad.  The  more  violent  the  attack,  the 
higher  the  temperature,  the  less  the  vitality,  and  the  warmer  the  weather, 
the  worse  is  the  prognosis.  When  the  infant  has  survived  the  very  acute 
symptoms  Avhich  appear  in  the  first  two  or  three  days,  the  prognosis  is 
much  more  favorable. 

Treatment. — Cholera  infantum  is  so  formidable  in  its  attack  that  it 
must  be  treated  most  energetically  if  Ave  hope  to  succeed  in  saving  the 
infant's  life.  The  indications  for  treatment  are  (1)  to  assist  the  effort  which 
nature  is  making  to  free  the  stomach  and  intestine  from  the  poison  Avhich 
is  in  them  ;  (2)  to  restore  the  surface  circulation,  which  is  so  seriously  in- 
terfered with  ;  (3)  to  supply  water  to  the  tissues,  which  are  being  drained 
to  so  grave  an  extent ;  and  (4)  to  support  the  strength  until  the  disease 
has  run  its  course. 


DISEASES   OF   THE   INTESTINE.  825 

The  poison  seems  to  act  ^vith  especial  virulence  on  those  portions 
of  the  economy  ^Yhere  it  is  most  concentrated, — namely,  the  stomach 
and  the  intestine.  We  therefore  have  at  first  extreme  irritation  of  these 
parts,  which  causes  increased  peristalsis,  and  later  vasomotor  paralysis, 
with  great  transudation  of  serum.  This  condition  of  the  gastro-enteric 
tract  is  to  be  especially  borne  in  mind  during  the  whole  course  of  our 
treatment. 

In  this  disease  we  should  not  attempt  to  use  any  remedy  which  works 
slowly.  The  condition  of  the  mucous  membrane  is  in  all  probability 
such  that  absorption  of  drugs  does  not  take  place  readily.  The  adminis- 
tration of  drugs  is,  therefore,  contraindicated,  for  they  may  later,  Avhen 
absorption  is  being  restored,  prove  fatal  by  their  cumulative  action. 
During  the  acute  stage  of  the  disease  the  digestive  functions  fail  to  act, 
and  therefore  food  of  any  kind  will  be  only  an  additional  source  of  irri- 
tation. 

Early  in  the  attack,  and  when  the  vomiting  has  not  caused  much 
prostration,  the  stomach  should  be  thoroughly  washed  out  with  warm 
water  and  the  intestine  should  be  irrigated.  If  the  rectal  temperature  is 
very  high,  ice-cold  water  may  be  used  for  irrigation.  When  the  vomiting 
has  continued  for  some  time  and  there  is  prostration  Avith  great  thirst,  the 
infant  should  be  allowed  to  suck  sterilized  ice-cold  water  from  the  bottle. 
At  first  nothing  else  should  be  given  by  the  mouth. 

The  infant  should  be  placed  at  once  in  a  warm  pack.  This  should 
be  done  by  wrapping  it  to  the  chin  in  sheets  wrung  out  of  water  at 
least  as  hot  as  38°  C.  (100.4°  F.J.  It  should  then  be  enveloped  in  a 
hot  blanket.  This  procedure  should  be  repeated  as  often  as  the  in- 
fant shows  signs  of  collapse  or  much  cyanosis  and  coldness  of  the  skin. 
This  is  the  best  method  that  we  know  of  to  restore  the  surface  cir- 
culation. In  extreme  cases  the  subcutaneous  injection  of  normal  salt 
solution  can  be  tried.  Care  should  be  taken  not  to  introduce  in  fifteen 
minutes  more  than  37.5  c.  c.  (1  drachm)  for  every  pound  of  the  cliild's 
weight. 

While  the  infant  is  in  the  hot  pack,  water  can  be  given  freely  by  the 
mouth,  and,  if  necessary,  small  and  frequently  repeated  doses  of  stimu- 
lants, unless  they  appear  to  excite  vomiting,  in  which  case  they  should  be 
given  hypodermically. 

If  the  vomiting  and  diarrhcEa  continue  to  be  excessive  after  this  treat- 
ment, small  doses  of  morphine,  0.0006  gramme  (y^-Q  grain),  and  atropine, 
0.00008  gramme  (g^  grain),  for  an  infant  a  year  old,  can  be  tried  hypo- 
dermically. The  effect  should  be  carefully  watched,  and  the  dose  re- 
peated if  necessary. 

If  an  absolutely  fresh  and  sterile  milk  can  be  obtained,  it  can  be  used 
as  a  food,  as  in  any  of  the  other  forms  of  gastro-enteric  diseases  which  we 
have  already  described,  but  for  some  days  the  percentages  of  the  elements 
in  the  milk  must  be  much  lessened,  and  the  child's  strength  must  be  sup- 


826  PEDIATRICS. 

ported   mostly  by  stimulants    freely  diluted  with  sterilized  water.     See 
Feeding,  pages  106  to  235. 

PROCTITIS. 

Proctitis  is  an  inflammation  of  the  rectum,  and  may  be  acute  or 
chronic.  It  is  usually  coincident  with  inflammation  of  the  colon,  but  may 
occur  alone  as  tlie  result  of  trauma  or  the  extension  of  inflammatory 
processes  around  the  anus. 

Symptoms. — The  symptoms  are  essentially  pain,  traces  of  blood  mixed 
with  mucus,  and  tenesmus. 

Diagnosis. — The  diagnosis  from  reflex  inflammatory  conditions  is  made 
by  direct  inspection. . 

Treatment. — The  treatment  is  to  keep  the  child  in  bed,  to  keep  the 
faeces  soft  with  laxatives,  to  cleanse  the  rectum,  and,  according  to  the 
especial  lesions,  use  astringents  or  soothing  injections.  When  there  is 
pain  or  tenesmus,  suppositories  of  opium  and  cocaine  are  indicated. 

APPENDICITIS. 

Etiology. — Inflammation  of  the  vermiform  appendix  in  children  is 
most  frequent  between  the  ages  of  five  and  fifteen  years,  and  is  not  of 
uncommon  occurrence;  It  is  very  rare  under  two  years.  Several  cases 
have  been  reported  as  early  as  seven  weeks.  Boys  are  more  often  attacked 
than  girls,  and  in  alDout  the  same  proportion  as  in  adults.  Functional 
disturbances  of  digestion,  constipation,  diarrhoea,  and  indiscretions  in  diet 
are  only  remotely  connected  with  the  etiology  of  the  disease.  Foreign 
bodies  are  infrequent,  despite  the  general  opinion,  but  the  presence  in  the 
appendix  of  faecal  concretions,  often  resembling  seeds  and  stones  of  fruits, 
are  very  common,  but  their  exact  relation  to  the  primary  cause  of  the 
inflammation  is  not  clear.  Intestinal  worms,  both  lumbricoid  and  the 
oxyuris,  have  been  found  within  the  appendix  and  presumably  have 
been  the  inciting  cause.  Direct  trauma,  as  from  a  blow  in  the  ab- 
_domen,  is  sometimes  a  definite  exciting  cause.  The  prevailing  opinion 
is  to  consider  the  process  an  infective  inflammation,  though  as  yet  no 
specific  organism  has  been  shown  to  cause  it.  On  the  contrary,  cul- 
tures of  the  colon  bacillus  alone,  or  mixed  infections  of  the  colon  ba- 
cillus associated  with  the  streptococcus,  pneumococcus,  staphylococcus 
albus  or  aureus,  the  bacillus  aerogenes,  and  certain  undetermined  anaero- 
bic organisms  are  found.  The  transformation  of  the  appendix  into  a 
closed  tube  is  to  be  considered  as  a  consequence  rather  than  a  cause 
of  appendicitis  (Brun). 

Pathological  Anatomy. — The  pathological  conditions  occurring  in  the 
course  of  an  appendicitis  are  exceedingly  varied,  and  will  only  be  out- 
lined. In  the  early  stages  of  a  purely  appendicular  lesion,  the  appendix  is 
in  normal  position  and  may  show  only  slight  swelling  and  congestion. 
Usually  it  is  voluminous  from  extensive  infiltration  of  its  walls,  very  tur- 


DISEASES  OF   THE   INTESTINE.  827 

gescenf,  and  often  shows  spots  of  ecchymoses  with  intense  congestion  of 
the  peritoneal  coat.  In  more  advanced  stages  the  mucosa  is  soft  and 
granular,  sometimes  gelatinous,  with  ecchymoses  and  ulcerations.  The 
muscular  coats  are  thickened  and  their  fibres  often  separated  by  minute 
or  extensive  accumulations  of  pus.  All  these  changes  may  develop  in 
from  twenty-four  to  thirty-six  hours  after  the  onset  of  symptoms.  Per- 
foration and  gangrene  of  the  appendix,  in  part  or  in  Avhole,  are  simply 
further  steps  in  the  inflammatory  process,  and,  according  to  Brun,  are 
especially  likely  to  occur  in  children. 

The  inflammation  is  rarely  confined  to  the  appendix,  but  by  extension 
involves  the  peritoneal  coat  of  the  appendix  and  the  peritoneum  itself. 
The  subsequent  course  is  very  variable.  The  process  may  remain  local, 
and  lead  to  a  peri-appendicular  inflammation,  in  which  the  appendix, 
caecum,  and  end  of  the  ileum  are  shut  off  from  the  rest  of  the  peritoneal 
cavity  by  false  membranes,  with  or  without  the  formation  of  pus  ;  or  the 
infection  may  spread  directly  from  the  appendix  to  the  general  peritoneal 
cavity,  with"  the  production  of  general  septic  peritonitis.  The  location  of 
the  pus  in  cases  of  abscess  formation  depends  to  some  extent  upon  the 
location  of  the  appendix,  in  which  there  is  considerable  variation.  It 
may  be  either  iliac,  pre-rectal,  sub-umbilical,  retro-caecal,  or  lumbar  in  its 
disposition. 

A  most  malignant  form  of  general  peritonitis  may  follow  a  simple 
parietal  appendicitis  without  perforation  or  gangrene  of  the  appendix,  and 
give  rise  to  a  clinical  picture  more  suggestive  of  septicaemia  than  of 
peritonitis. 

A  simple  appendicitis,  sometimes  called  catarrhal,  may  produce  so 
much  thickening  of  the  walls  and  infiltration  of  the  submucosa  with  leuco- 
cytes, and  subsequent  formation  of  granulation  tissue,  as  to  cause  an 
obliteration  of  the  lumen  of  the  appendix.  If  the  lumen  is  completely 
obliterated,  it  may  render  the  patient  immune  to  subsequent  attacks,  but 
if  only  partial,  it  favors  the  collection  of  pockets  of  pus  and  cyst-formation, 
and  the  organ  is  a  constant  source  of  danger. 

Ulcerative  appendicitis  may  be  caused  by  the  presence  of  concretions 
or  by  the  action  of  micro-organisms.  The  presence  of  concretions,  how- 
ever, may  not  be  accompanied  by  any  inflammatory  or  necrotic  reaction. 
Typhoid  and  tubercular  ulcerations  of  the  appendix  are  not  uncommon 
in  their  respective  diseases,  and  an  actinomycotic  ulcer  has  also  been 
described. 

Symptoms. — Sudden  pain  in  the  abdomen,  referred  to  the  umbilicus  or 
to  the  right  iliac  fossa,  with  tenderness  on  deep  pressure  in  the  region  of 
the  appendix,  associated  with  a  fever  of  moderate  or  high  grade  leucocy- 
tosis  and  gastro-intestinal  symptoms,  usually  mark  the  onset  of  an  acute 
inflammation  of  the  appendix.  CHnically  it  is  convenient  to  distinguish 
between  certain  types  of  the  disease. 

Simple  Appendicitis.— This  is  the  least  severe  of  the  acute  forms,  and 


828  PEDIATRICS. 

is  characterized  by  its  sudden  onset  and  short  duration.  Without  any 
prodromal  symptoms  the  child  is  seized  with  sudden,  severe  abdominal 
pain  at  about  the  level  of  the  umbilicus  and  more  to  the  right  than  to  the 
left.  Vomiting,  in  some  cases  only  nausea,  follows.  There  is  moderate 
fever.  The  pain  is  continuous,  and  the  bowels  are  usually  constipated. 
Tenderness  over  the  region  of  the  appendix  with  a  unilateral  rigidity  of 
the  muscles  is  the  most  important  sign  by  which  we  exclude  other  causes 
of  abdominal  pam.  The  temperature  is  moderate,  23.5°  to  24.1°  C.  (100° 
to  101°  F.).  lasting  a  day  or  two.  The  acute  symptoms  subside  in  from 
twenty-four  to  forty-eight  hours,  but  the  tenderness  is  apt  to  remain  for 
several  days,  at  the  end  of  which  time  the  abdomen  is  sometimes  so  re- 
laxed as  to  enable  one  by  careful  examination  to  feel  the  slightly  thick- 
ened appendix.  These  mild  cases  probal^ly  occur  much  oftener  in  children 
than  are  diagnosed. 

Appendicitis  with  Periappendicular  Peritonitis. — This  is  the  more 
common  form,  formerly  recognized  as  perltyphUtis,  and  in  its  mildest 
grade  is  not  to  be  distinguished  clinically  from  the  severer  t^^Des  of  a 
simple  appendicitis.  The  initial  symptoms  are  more  exaggerated,  but  are 
the  same  in  character  as  in  a  simple  appendicitis.  The  digestive  symptoms 
are  much  more  pronounced.  The  vomiting  is  apt  to  be  repeated,  and  the 
temperatm-e  much  higher,  39°  to  40°  C.  (102.2°  to  104°  F.).  The  pulse 
is  rapid.  112  to  120  per  minute,  and  the  pain  and  localized  tenderness  is 
more  intense.  After  a  lapse  of  some  hours,  if  the  abdomen  is  not  too 
tense,  we  may  sometimes  feel  in  the  right  iliac  region  an  incUstinct  thick- 
ening, sometimes  a  definite  mass,  but  the  swelling  may  not  be  located 
until  the  child  is  under  the  influence  of  an  autesthetic.  There  is  apt  to 
be  leucocytosis,  though  one  must  not  be  misled  by  a  normal  wliite  blood 
count.  In  some  cases,  under  expectant  treatment,  these  symptoms  will 
gradually  subside  m  the  course  of  a  week  or  ten  days,  and  mth  the  alle- 
viation of  the  acute  pain  and  tenderness  the  swelling  of  the  appendix  and 
surrounchng  tissue  is  more  readily  recognized.  In  time  this  mass  may 
entirely  disappear  so  far  as  external  palpation  can  determine,  or,  on  the 
~other  hand,  some  induration  may  remain  after  complete  establishment  of 
health. 

If  the  inflammatory  process  ends  m  abscess  formation  the  persistence 
of  the  fever  and  the  presence  of  leucocytes  aid  in  the  diagnosis.  The 
return  of  the  fever  after  its  subsidence  is  also  indicative  of  the  advent  of 
suppuration.  The  absence  of  fever,  however,  cannot  be  taken  as  positive 
evidence  of  the  absence  of  pus.  If  the  swelling  increases  m  size  or  if  it 
remains  stationary  we  strongly  suspect  that  there  is  a  local  accumulation 
of  pus.  If  the  pus  has  once  formed  it  may  terminate  by  absorption  or 
by  perforation  externally  or  into  some  portion  of  the  intestines,  vagina,  or 
bladder,  but — and  this  should  always  be  borne  m  mind  by  the  physician 
who  takes  the  responsilDility  of  expectant  treatment — ^it  may  rupture  into 
the  peritoneal  cavity,  usually  with  the  result  of  a  fatal  septic  peritonitis. 


DISEASES    OF  THE    INTESTINE.  829 

Appendicitis  with  General  Suppurative  Peritonitis. — Aside  from 
those  cases  of  general  peritonitis  which  are  caused  by  a  rupture  of  an 
appendix  abscess  into  the  peritoneal  cavity,  there  are  others  of  general 
peritonitis  in  which  the  infection  starts  from  a  diseased  appendix  with 
symptoms  of  such  rapid  development  as  to  indicate  a  general  peritonitis 
almost  from  the  very  beginning.  There  is  sudden  severe  pain  in  the 
region  of  the  umbihcus  rapidly  spreading  over  the  whole  abdomen,  but 
with  its  greatest  intensity  on  the  right  side.  The  vomiting  is  incessant, 
and  the  constipation  so  sudden  and  complete  as  to  suggest  intestinal  ob- 
struction. The  temperature  rises  suddenly  to  39°  to  40°  C.  (102.2°  to 
104°  F.),  and  the  pulse  is  increased  to  130  to  140  per  minute.  The  ab- 
domen rapidly  becomes  rigid  throughout,  and  deep  palpation  is  impossible. 
The  tenderness  is  general,  but  most  marked  on  the  right  side  in  the 
neiglilDorhood  of  the  appendix.  The  symptoms  progress  rapidly.  The 
vomiting  of  bile  is  followed  by  that  of  faeces.  The  abdomen  becomes  dis- 
tended. The  respiration  is  labored.  Delirium  often  sets  in.  Aside  from 
the  localized  tenderness  and  rigidity,  the  examination  of  the  abdomen  is 
negative,  for  the  amount  of  intraperitoneal  fluid  is  too  small  to  be  recog- 
nized by  percussion,  though  at  times  a  rectal  examination  gives  evidence 
of  fluid  in  the  cul-de-sacs.  Without  an  early  operation,  death  usually 
ensues  in  these  cases  in  from  two  to  four  or  five  days. 

There  is  still  another  form  of  appenchcitis  with  diffuse  peritonitis,  de- 
scribed by  Brun,  Jalaguier,  and  others,  which  is  the  most  malignant  and 
rapid  of  all,  and  in  its  course  suggests  a  septictemia  having  its  origin  in  a 
virulently  infected  appendix.  Its  onset  is  quite  different  fi'om  the  type  of 
disease  just  described.  It  begins  like  an  attack  of  acute  intestinal  indi- 
gestion \dth  vomiting  and  f^tid  diarrhcBa,  rarely,  if  ever,  with  constipa- 
tion. Neither  the  pain  nor  the  tenderness  in  the  iliac  fossa  is  so  marked 
as  in  the  other  cases.  The  abdomen  is  soft,  flat,  and  easily  palpable,  and 
with  almost  complete  absence  of  resonance  on  percussion.  The  progress 
is  rapid.  The  features  are  anxious,  leaden-colored,  the  eyes  sunken  and 
surrounded  by  dark  rings.  The  thirst  is  keen,  the  respiration  rapid  and 
shallow.  There  is  extreme  restlessness.  The  temperature  at  the  first 
may  reach  39°  C.  (102.2°  F.),  but  on  the  second  day  is  more  apt  to  be 
37°  C.  (98.6°  F.)  or  below,  in  striking  contrast  to  the  w-eak,  rapid  pulse 
of  150  to  160.  The  mind  remains  clear  to  the  end,  without  any  change  in 
the  abdominal  symptoms,  and  death  often  supervenes  within  thirty-six 
to  forty-eight  hours,  rarely  extending  beyond  three  or  four  days. 

Chronic  Appendicitis. — An  appendix  once  inflamed  is  prone  to  re- 
current attacks,  with  the  train  of  events  connected  with  the  primary 
attack.  The  cause  for  this  probably  lies  in  an  obliterative  appendicitis 
wdth  or  without  adhesions,  or  perhaps  from  a  localized  abscess  circum- 
scribed by  dense  fibroid  tissue.  The  attacks  may  recur  at  intervals  of  a 
few  months,  and  finally  cease  or  develop  into  an  acute  attack  which  may 
run  a  typical  course.     Chronic  appendicitis  may,  however,  manifest  itself 


830  PEDIATRICS. 

from  the  beginning  as  indefinite  twinges  of  pain  in  tlie  riglit  iliac 
fossa,  brought  on  especially  by  over-exertion  and  fatigue,  without  ever 
developing  alarming  symptoms,  and  with  but  little  else  in  the  way  of 
symptoms  ;  on  the  other  hand,  these  inconstant  pains  may  be  prod- 
romal symptoms  of  a  susceptible  appendix,  which  later  becomes  acutely 
inflamed. 

Diagnosis. — The  diagnosis  of  appendicitis  in  young  children  is  often 
made  difficult  by  the  inability  of  the  child  to  locate  accurately  his  sense 
of  pain,  and  to  appreciate  the  distinction  between  pain  and  tenderness. 
Moreover,  the  contraction  of  his  abdominal  muscles  and  his  inability  to 
relax  them  at  will  renders  the  result  of  palpation  less  certain.  The 
presence  of  fever  and  localized  tenderness  in  the  right  iliac  fossa  are  the 
principal  points  in  the  exclusion  of  hepatic  and  renal  colic.  Intestinal 
colic  is  more  often  associated  with  diarrhoea  than  with  constipation,  and 
here  again  tlie  localized  tenderness  is  a  crucial  point' in  the  diagnosis.  It 
is  well  established  that  in  pneumonia  in  children  the  pain  is  frequently 
referred  to  the  abdomen,  but  careful  attention  to  the  symptoms  and 
course  of  the  disease  will  enable  one  to  distinguish  between  the  two  con- 
ditions. An  appendix  abscess  arising  from  an  appendix  unusually  placed 
might  easily  be  confounded  with  a  perinephritic  abscess,  but  in  either 
case  operation  is  indicated,  and  the  error  in  diagnosis  should  not  prejudice 
the  interests  of  the  child.  Appendicitis  with  the  sudden  onset  of  septic 
peritonitis  may  readily  suggest  an  intestinal  obstruction,  but  the  fever, 
localized  tenderness,  and  leucocytosis  are  not  hkely  to  occur  in  the  latter 
condition.  In  intussusception  the  straining,  tenesmus,  and  small  and 
frequent  discharges  of  blood  and  mucus,  and  the  sausage-like  tumor, 
which  can  often  be  felt  in  the  region  of  the  transverse  colon,  usually  suf- 
fice for  a  diagnosis.  Moreover,  appendicitis  is  very  rare  under  two  years, 
and  intussusception  is  very  common.  In  certain  cases  the  two  conditions 
simulate  each  other  very  closely.  Perforation  of  gastric  ulcer,  pus  tubes, 
and  pelvic  peritonitis,  abscess  of  the  broad  ligament,  acute  pancreatitis, 
appendicular  hypochondriasis  and  hysteria,  which  may  in  the  adult  be 
mistaken  for  appendicitis,  are  not  likely  to  occur  in  infants  and  young 
children,  but  in  older  children  should  be  borne  in  mind.  An  acute  in- 
flammation of  the  gall-bladder  and  appendicitis  are  often  confounded,  and 
an  unusual  position  of  the  appendix  should  always  be  remembered. 

Prognosis. — The  prognosis  depends  largely  upon  how  early  the  diag- 
nosis is  made  and  the  skill  of  the  surgeon  who  is  called  for  consultation 
and  operation.  Cases  undoubtedly  recover  in  many  instances  without 
operation,  but  the  extreme  gravity  of  the  results  of  an  extension  of  the 
inflammation  to  the  peritoneum,  and  the  realization  that  this  accident  may 
occur  at  almost  any  time,  even  in  the  cases  w'hich  are  apparently  running 
a  mild  course,  render  general  statistics  of  Kttle  value  in  the  considera- 
tion of  an  individual  case.  We  should  not  lose  sight  of  the  fact  that  in 
infancy  we  see  most  frequently  the  very  severe  and  acute  forms  of  the 


DISEASES    OF   THE   INTESTINE.  831 

disease,  and  there  is  the  special  tendency  to  perforation  and  gangrene  and 
extension  to  the  peritoneum,  with  its  very  serious  consecjuences. 

Treatment. — Personally,  we  consider  tha  disease  one  for  surgical  obser- 
vation and  treatment.  It  is  safer  to  call  the  surgeon  in  consultation  early 
than  late,  and  if  the  diagnosis  is  determined  it  is  wiser  to  trust  to  his 
judgment  as  to  the  expediency  of  immediate  or  delayed  operation  than 
for  the  physician  himself  to  attempt  to  decide.  There  is  no  medical  treat- 
ment other  than  that  which  is  purely  symptomatic.  Absolute  rest  in 
bed,  irrespective  of  the  severity  of  the  symptoms,  is  of  first  importance  ; 
local  applications  of  ice  should  be  used  to  control  the  pain,  or,  if  the 
child  objects,  as  is  frequently  the  case,  hot  fomentations  should  be  tried. 
Cathartics  and  laxatives  should  be  avoided,  and  the  bowels  moved  by 
enemata.  Blisters  should  not  be  used.  Opium  is  strongly  objected  to 
by  surgeons  as  tending  to  mask  the  symptoms  ;  if  it  can  be  avoided,  it  is 
far  better  to.  do  so  ;  but  very  small  doses,  sufficient  to  keep  the  patient 
from  excessive  pain  and  fairly  c{uiet,  are  probably  in  children  a  lesser 
danger  than  that  which  would  be  caused  by  hours  of  pain,  crying,  and 
intense  restlessness.  If  no  operation  could  be  performed  we  should  prefer 
to  trust  to  opium  in  the  early  stages  rather  than  to  cathartics. 

FISTULA. 
Fistulae  in  ano  is  not  a  very  common  condition  in  infancy  or  early 
childhood,  but  is  met  with  at  times.     The  condition  has  the  same  charac- 
teristics as  in  the  adult,  and  should  be  treated  in  the  same  way. 

INTESTINAL  NVORMS. 

The  worms  which  are  found  in  the  intestines  of  infants  and  children 
are  the  same  as  those  which  occur  in  older  patients.  The  only  ones, 
however,  which  are  common  and  important  enough  to  speak  of  are  the 
oxyuris  vermicularis  (pin-worm),  the  ascaris  luinbricoides  (roand-worm), 
the  tcenia  solium,  and  the  tcenia  mediocaneUafa  (tapeworms). 

Oxyuris  Vermicularis. — The  oxyuris  vermicularis  is  a  minute  worm, 
which  looks  like  a  little  piece  of  white  thread.  The  female  is  from  0.6  to 
1.2  cm.  {I  to  J  inch)  in  length.  The  male  is  about  one-third  as  large,  and 
has  the  tail  rolled  into  a  spiral.  Their  development  takes  place  in  the 
large  intestine,  and  the  mature  worms  deposit  their  eggs  in  the  rectum. 
The  eggs  enter  the  intestine  through  the  mouth,  and  children  are  very  apt 
to  reinfect  themselves  by  carrying  the  eggs  on  the  fingers  or  under  the 
nails  to  their  mouths. 

These  worms  sometimes  exist  in  large  numbers,  and  their  development 
is  so  rapid  that  it  is  often  difficult  to  dislodge  them  completely.  The 
most  common  symptom  of  the  oxyuris  is  an  intense  itching  about  the 
anus.  The  sleep  of  the  child  is  disturbed  by  this  irritation,  and  various 
nervous  symptoms  develop  in  children  who  are  infested  with  this  para- 
site. Thus  incontinence  of  urine  sometimes  results.  In  girls  the  parasite, 
by  migrating  from  the  anus  to  the  vulva,  may  cause  a  vulvo-vaginitis. 


832 


PEDIATRICS. 


Diagnosis. — The  diagnosis  of  the  presence  of  these,  as  of  other  intes- 
tinal parasites,  can  be  made  only  by  finding  the  worm  or  its  ova  in  the 
intestinal  discharges.  When  they  are  suspected,  an  enema  of  clear  water 
should  be  given.  If  the  parasites  are  present,  they  will  be  dislodged, 
and  careful  inspection  will  disclose  their  presence.  Whenever  there  are 
symptoms  of  reflex  irritation  in  the  neighborhood  of  the  anus  or  the 
genital  organs,  the  oxyuris  should  be  suspected   and   sought   for.     The 

Tig.   178. 


Oxyuris  vermicularis.    Ascaris  lumbricoides. 


parasites  can  often  be  found  in  the  faecal  discharges,  and  in  some  cases 
they  can  be  seen  by  simply  stretching  open  the  anus  and  examining  the 
mucous  membrane  of  the  rectum. 

Treatment. — Although  most  of  the  worms  are  in  the  rectum,  yet  they 
also  infest  the  upper  parts  of  the  intestine,  and  therefore  sometimes  can- 
not be  reached  by  enemata.  In  many  cases  enemata  of  sal t-and- water 
are  sufficient  to  produce  a  cure,  but  in  some  cases  the  salt,  even  in  small 
amount,  is  so  irritating  that  it  cannot  be  used.  Infusions  of  quassia  may 
also  be  employed  as  enemata.  One  of  the  most  effective  methods  of  dis- 
lodging the  parasite  is  to  give  every  evening  at  bedtime  an  injection  of  60 


DISEASES   OF   THE   INTESTINE.  833 

c.c.  (2  ounces)  of  sweet  oil.  This  is  allowed  to  remain  in  the  rectum  for 
five  or  six  minutes,  and  a  large  enema  of  water  is  then  used  to  wash  out 
the  oil,  which  usually  carries  with  it  the  parasites  from  the  lower  colon 
and  the  rectum.  Care  must  be  taken  in  regard  to  cleanliness,  so  as  to 
prevent  reinfection. 

When  this  treatment  is  not  sufficient,  lozenges  of  santonin,  0.01  to  0.03 
gramme  (^  to  i  grain),  according  to  the  age,  may  be  given  two  or  three 
times  daily.  We  have  seen  obstinate  cases  yield  to  a  treatment  consisting 
of  free  catharsis  by  Epsom  salts  every  morning  for  three  consecutive 
days,  followed  each  day  by  irrigation  of  the  colon  with  salt  solution  after 
the  salts  have  ceased  to  act. 

Every  two  or  three  days  a  cathartic,  such  as  castor  oil  or  calomel, 
should  be  given.  Care  must  be  used  in  giving  santonin  not  to  produce 
symptoms  of  poisoning,  such  as  gastro-enteric  irritation,  dizziness,  and 
yellow  vision.  This  occurrence,  however,  will  not  be  common  if  in  each 
case  the  effect  of  the  drug  on  the  child  is  carefully  watched.  Serious 
symptoms,  such  as  convulsions,  have  been  caused  by  a  lack  of  care  in 
using  this  drug  in  young  children. 

Under  this  treatment,  aided  by  high  rectal  injections,  the  worms  can 
in  most  cases  be  eradicated.  We  have,  however,  met  with  very  intrac- 
table cases  m  which  months  and  even  years  had  elapsed  before  treatment 
of  any  kind  was  successful.  In  such  cases  temporary  relief  can  be  obtained 
by  giving  the  child  each  night,  or  two  or  three  times  a  week,  a  small 
enema  of  oil. 

Ascaris  Lumbricoides. — The  ascaris  lumbricoides  is  a  long,  cylin- 
drical, yellowish-white  or  reddish-yellow  worm,  pointed  at  both  extremi- 
ties. The  male  is  distinguished  from  the  female  by  the  fact  that  it  is 
smaller  and  is  always  rolled  upon  itself,  while  the  female  is  straight.  The 
length  of  the  male  is  from  10.4  to  18  cm.  (4  to  7  inches),  and  that  of  the 
female  from  15.5  to  28.5  cm.  (6  to  11  inches).  The  eggs  of  this  worm  are 
oval  in  shape,  0.075  mm.  long  and  0.058  mm.  wide.  When  they  are  first 
passed  they  are  almost  transparent,  but  they  soon  become  yellowish  and 
opaque.  These  eggs  are  not  developed  within  the  intestine,  but  may  pass 
out  with  the  faeces.  They  are  very  tenacious  of  life,  and  may  develop 
under  favorable  circumstances  after  many  years.  The  embryos  are  de- 
veloped outside  of  the  body,  and  reach  the  intestine  with  the  drinking- 
water,  where  they  develop  into  the  mature  worm. 

The  habitat  of  the  worm  is  usually  in  the  small  intestine.  It  may, 
however,  pass  through  the  rectum  either  with  the  faeces  or  alone,  and 
may  migrate  into  the  stomach,  oesophagus,  or  nose.  Sudden  death  has 
resulted  from  the  entrance  of  these  worms  into  the  air-passages.  They 
may  also  at  times  enter  the  common  and  cystic  bile-ducts,  and  they  have 
even  penetrated  farther  and  caused  abscess  of  the  liver.  There  is  no 
danger  of  their  perforating  a  normal  intestine,  but  when  ulceration  has 
been  present  perforation  has  occurred.; 

53 


834  PEDIATRICS. 

Symptoms. — There  are  no  especial  symptoms  produced  by  this  worm, 
and  we  can  diagnosticate  its  presence  only  by  seeing  it  or  by  finding  the 
eggs  in  the  faecal  discharges.  The  worm  may  in  some  instances  produce 
a  feeling  of  discomfort  or  even  colic  in  the  region  of  the  umbilicus. 
Neither  of  these  symptoms,  however,  can  be  depended  upon,  and  an 
anthelmintic  is  required  to  determine  whether  the  parasite  is  present.  In 
certain  cases  convulsions  in  children  have  been  followed  by  the  passage 
of  a  lumbricoid  worm.  This,  however,  cannot  be  accepted  as  conclusive 
evidence  that  the  convulsion  was  dependent  upon  the  worm,  as  we  have 
met  with  instances  in  which  large  numbers  of  these  worms  were  found  at 
the  autopsy  in  children  who  during  life  showed  no  nervous  symptoms 
whatever.  As  a  rule,  the  presence  of  these  parasites  in  the  intestine, 
unless  in  very  large  numbers,  is  not  especially  important. 

Treatment. — The  most  efficacious  treatment  of  this  form  of  parasite 
is  in  the  form  of  santonin,  which  should  be  given  in  the  same  doses  and 
with  the  same  caution  as  we  have  already  described  in  speaking  of  the 
treatment  of  the  oxyuris.  Instead  of  santonin,  the  freshly  prepared  fiuid 
extract  of  spigelia  and  senna  in  doses  of  1.87  c.c.  (J  drachm)  for  a  child 
two  years  old,  and  3.75  c.c.  (1  drachm)  for  older  children,  can  be  given 
two  or  three  times  a  day,  care  being  taken  not  to  produce  too  much  irri- 
tation. The  oil  of  chenopodium,  0.012  to  0.018  c.c.  (2  to  3  minims),  on 
sugar,  for  a  child  two  or  three  years  old,  and  0.50  to  0.60  c.c.  (8  or  10 
minims)  for  older  children,  can  also  be  given.  A  cathartic  should  be  used 
in  connection  with  these  drugs,  as  well  as  with  santonin. 

Taeniae  {tapeworms).  —  The  forms  of  taenia  which  most  frequently 
occur  in  children  are  the  toenia  solium  and  the  tcenia  mediocaneUata.  The 
tcBnia  solium  has  a  slight  projection  at  the  apex  of  its  head,  around  which 
are  a  series  of  hooks,  and  below  which  are  four  sucking-disks.  The  tcenia 
mediocaneUata,  or  beef  tapeworm,  is  the  variety  which  occurs  most  fre- 
quently in  children.  It  has  a  blunter  hook  than  the  taenia  sohum,  and 
does  not  have  the  circle  of  hooks.  These  worms  vary  in  length  from  605 
to  1512.5  cm.  (20  to  50  feet).  There  is  nothing  especial  to  be  said  con- 
"^cerning  these  worms,  and  we  refer  to  them  merely  because  at  times  they 
occur  in  early  life.  They  are  never  met  with  in  nursing  children  when 
breast-milk  forms  the  exclusive  diet.  There  is  reason  to  suppose  that 
raw-beef  juice  may  carry  the  eggs  of  the  taenia.  There  are  no  especial 
symptoms  produced  by  this  worm,  and  the  diagnosis  is  made  entirely  by 
finding  the  segments  in  the  faeces.  There  is  no  especial  danger  from  the 
presence  of  the  tapeworm. 

Treatment. — The  treatment  employed  for  expelling  this  worm  is  the 
same  in  children  as  in  adults,  but  we  should  be  very  careful  not  to  irritate 
too  much  the  sensitive  gastro-enteric  mucous  membrane  of  the  young  child. 
The  child  should  first  be  treated  with  laxatives,  so  as  to  free  the  intestine. 
Food  should  be  withheld  from  the  early  evening  until  as  late  as  possible 
the  next  day.     An  anthelmintic  should  then  be  given,  followed  in  one  or 


DISEASES    OF   THE    INTESTINE. 


835 


two  hours  by  a  cathartic.  This  usually  results  in  the  expulsion  of  a  large 
mass  of  segments.  Great  care  should  be  taken  to  prevent  the  head  from 
breaking  off  before  it  is  expelled.  If  the  head  remains,  the  worm  grows 
again  and  the  treatment  has  been  useless.  The  anus  should  be  carefully 
dilated  during  the  expulsion  of  the  worm.  Sitting  on  a  vessel  of  hot 
water  seems  to  help  to  prevent  the  head  from  breaking  off. 


Fig.   179. 


Tfenia.    I.,  without  head  ;  II.,  vrith  head. 


There  is  no  anthelmintic  which  we  have  found  pre-eminently  successful 
in  expelling  the  t^nice.  One  of  the  most  harmless  is  the  alkaloid  pelletierine 
from  pomegranate.  The  tannate  of  pelletierine  can  be  given  to  a  child 
from  three  to  five  years  old  in  the  dose  of  from  0.01  to  0.03  gramme 
(i  to  I"  grain).  As  dizziness  and  headache  are  sometimes  complained  of, 
it  is  well  to  have  the  child  kept  in  bed  and  lying  down  until  the  effect  of 
the  anthelmintic  has  passed  off.  The  oleoresin  of  male  fern  may  also  be 
used.     The  dose  is  0.94  to  1.88  gramme  (^  to  J  drachm).     The  cathartic 


836  PEDIATRICS. 

which  is  most  useful  in  these  cases  is  Epsom  salt,  7.5  to  15  grammes 
(2  to  4  drachms). 

It  is  hardly  worth  while  to  mention  the  other  numerous  anthelmintics 
which  have  been  recommended,  as  they  are  usually  inefficient. 

If  the  head  of  the  worm  is  not  obtained  and  if  a  considerable  portion 
of  the  segments  is  discharged  as  a  result  of  the  treatment,  it  is  desirable 
to  wait  a  few  months  before  making  a  second  attempt  to  dispel  the  para- 
site. The  reappearance  of  segments  in  the  stools  indicates  that  the  growth 
of  the  worm  is  sufficient  to  justify  another  attempt  to  dislodge  it. 


DIVISION    XIII. 

DISEASES    OF  THE    LIVER,    PANCREAS,    SPLEEN,   AND 

PERITONEUM. 


DISEASES  OF  THE  LIVER. 

The  size  of  the  liver  is  in  infancy  ven^  large  relatively,  and  in  early 
childhood  somewhat  larger  than  at  a  later  period  of  life.  This  is  of 
importance  in  making  a  diagnosis  as  to  the  increase  or  decrease  of  the 
normal  hepatic  area.  These  changes,  although  varying  so  much  at  dif- 
ferent ages  from  infancy  to  puberty,  yet  in  the  intermediate  extremes  of 
size  show  such  slight  differences  that  nothing  definite  can  be  stated  in 
regard  to  them.  In  early  life,  however,  we  may  say  that  the  edge  of  the 
liver  may  be  felt  about  1.5  to  2  cm.  (|-  to  |  inch)  below  the  edge  of  the 
ribs  in  front,  and  that  the  hepatic  dulness  extends  up  to  the  fifth  inter- 
space or  rib  in  front,  to  the  seventh  interspace  in  the  axillary  line,  and  to 
the  ninth  space  or  rib  behind. 

The  left  lobe  of  the  liver  is  relatively  larger  in  the  child  than  in  the 
adult.  (Steffen.)  In  determining,  however,  whether  or  ngt  the  liver  is 
of  abnormal  size  we  must  consider  that  a  downward  displacement  of  a 
normal  liver  may  take  place  from  relaxation  of  the  ligaments  and  of  the 
abdominal  walls  in  cases  of  wastmg  disease,  also  from  pressure,  as  from  a 
pleuritic  effusion  or  from  thoracic  deformity  as  in  rhachitis.  Upward  dis- 
placement also  may  take  place  from  ascites  and  other  causes  of  abdominal 
distention. 

Diseases  of  the  liver  are  not  common  in  infancy  and  childhood,  as  the 
inciting  causes  of  hepatic  disease  are  usually  not  present  in  early  life. 
When  hepatic  disease  is  present,  it  is  commonly  secondary'  to  some  gen- 
eral disease. 

Congenital  malpositions  and  malformations  of  the  liver  may  occur,  but 
those  of  especial  clinical  interest  are  chiefly  connected  with  the  bile-ducts, 
and  have  been  described  on  page  294. 

The  acquired  pathological  lesions  which  occur  in  the  liver  in  infancy 
and  childhood  do  not  differ  from  those  which  are  met  A\ith  in  later  life. 
A  rapid  increase  and  decrease  in  the  size  of  the  liver  are  not  infrequently 
met  with  in  disease,  and  careful  measurements  have  shown  that  even  a 

S37 


838  PEDIATRICS. 

very  slight  disturbance  of  health  may  cause  in  young  children  a  variation 
of  from  2  to  4  cm,  (|  to  IJ  inches)  in  the  size  of  the  liver. 

In  most  diseases  which  are  accompanied  by  hepatic  disturbance,  it  is 
much  more  common  to  have  the  liver  enlarged  than  diminished  in  size. 

lOTEBUS. 
Icterus  is  a  symptom  of  a  number  of  diseases,  as  well  as  of  disease 
of  the  liver,  but  it  so  commonly  occurs  when  the  liver  is  either  directly 
or  indirectly  affected  that  it  is  best  spoken  of  in  connection  with  hepatic 
disease.  The  icterus  which  arises  at  birth,  either  of  the  temporary  form, 
such  as  icterus  neonatorum,  or  from  obliteration  of  the  bile-ducts,  has 
already  been  described  on  page  294,  but  it  may  be  added  to  what  was 
said  regarding  the  former  that  there  is  some  reason  to  suppose  that  it  may 
be  caused  by  the  ductus  venosus  remaining  patent  at  birth.  Icterus  aS  a 
symptom  of  acute  and  chronic  duodenal  indigestion  has  been  described  on 
page  803.  It  must  not  be  assumed  that  there  is  necessarily  hepatic  dis- 
ease because  icterus  is  present,  as  any  slight  mechanical  disturbance  in  the 
liver  produced  by  diseased  conditions  elsewhere  may  cause  icterus.  In 
these  cases,  even  though  the  liver  may  be  somewhat  enlarged,  it  is  not  a 
symptom  of  much  import,  and  the  liver  is  soon  restored  to  its  normal 
condition,  provided  that  the  original  disease  has  disappeared  or  has  ceased 
to  produce  hepatic  disturbance.  In  addition  to  this  obstructive  class  of 
cases,  icterus  may  also  occur  as  a  symptom  in  septic  infiammation  of 
the  umbiUeal  vein.  In  these  cases  the  liver  is  apt  to  be  enlarged  and 
tender.  Convulsions  commonly  occur.  Vomiting,  diarrhoea,  abdominal 
swelling,  pain,  and  tenderness  are  present.  The  temperature  is  high. 
The  respirations  are  increased,  and  death  usually  occurs  from  exhaustion 
or  from  septic  inflammation  of  the  pleura,  pericardium,  or  other  parts. 

ACUTE  YELLOW  ATROPHY  OP  THE  LIVER. 
It  is  uncommon  for  the  liver  to  be  decreased  in  size,  but  this  occurs  in 
the  very  rare  cases  of  acute  yellow  atrophy  at  times  met  with  in  children. 
~~The  disease  is  insidious  in  its  onset,  and  is  characterized  by  general  symp- 
toms of  malaise,  with  icterus  and  urine  containing  bile.  In  the  beginning 
of  the  disease  the  liver  is  enlarged,  but  in  the  later  stages  it  is  decidedly 
diminished.  Cerebral  symptoms  and  vomiting  are  quite  prominent,  and 
death  invariably  occurs. 

CONGESTION  OP  THE  LIVER. 

Although  an  acute  congestion  of  the  liver  may  occur,  as  from  certain 
poisons  and  in  the  course  of  malaria,  yet  by  far  the  most  common  form  is 
the  subacute  or  chronic  condition  which  results  from  stasis  in  the  venous 
system,  produced  by  cardiac  disease  and  certain  pulmonary  conditions 
which  interfere  with  the  circulation. 

There  are  no  especial  hepatic  symptoms  beyond  enlargement  of  the 


DISEASES   OF   THE    LIVER.  839 

organ,  and  the  treatment  is  that  of  the  primary  disease.  This  enlarge- 
ment may  occur  from  a  number  of  causes,  among  which  is  mechanical 
congestion,  arising  in  the  course  of  cardiac  disease. 

FATTY  INFILTRATION   OF  THE  LIVER. 

Fatty  liver  in  early  life  is  quite  common,  especially  in  infants,  and  does 
not  differ  pathologically  from  that  which  is  met  with  at  a  later  period. 
The  liver  may  or  may  not  be  enlarged,  and  there  are  no  especial  hepatic 
symptoms,  such  as  icterus  or  ascites,  which  characterize  this  condition,  the 
symptoms  being  those  of  the  general  disease  from  which  the  child  is  suf- 
fering. It  may  be  found  associated  with  a  number  of  diseases,  especially 
suppurative  inflammations,  pneumonia,  rhachitis,  tuberculosis,  and  wast- 
ing diseases,  especially  with  those  which  are  associated  with  disturbances 
of  digestion.  When  the  liver  is  enlarged  from  this  cause  its  surface  is 
found  to  be  smooth  and  there  is  no  pain  nor  tenderness  on  palpation. 

The  prognosis,  unless  the  disease  is  dependent  upon  some  incurable 
disease  elsewhere,  is  fairly  good. 

The  treatment  is  essentially  dietetic,  hygienic,  and  that  of  the  causative 
disease. 

SUPPURATIVE  HEPATITIS.— ABSCESS  OF  THE  UVER. 

Abscess  of  the  liver  is  an  exceedingly  rare  condition  in  both  infants 
and  children.  Even  when  septic  infection  of  the  umbilical  vessels  has 
taken  place  at  birth,  it  has  been  found  that  only  in  a  very  small  propor- 
tion of  these  cases  has  hepatic  abscess  resulted. 

Etiology. — ^According  to  Musser's  analysis  of  thirty-four  reported 
cases,  the  average  age  was  nine  years,  and  the  youngest  one  year.  The 
causes  in  these  cases  were  from  traumatism,  from  round-worms  entering 
the  bile-ducts,  from  pylephlebitis  in  four  cases,  from  umbilical  phlebitis 
once,  from  pyaemia  twice,  and  once  each  from  pelvic  peritonitis,  dysentery, 
perityphlitis,  malaria,  and  tuberculosis  of  the  lungs.  Musser  therefore  con- 
cludes that  the  general  conditions,  such  as  climate  and  habits  of  life,  which 
are  marked  etiological  factors  in  adults,  are  not  of  significance  in  children. 

Symptoms. — The  onset,  the  progress,  and  the  duration  of  the  disease 
depend  greatly  on  the  primary  cause.  Icterus  may  occur,  but  usually  is 
not  marked,  and  is  not  of  much  significance.  The  local  symptoms  con- 
nected with  the  liver  are  the  same  as  in  adult  life,  and  are  chiefly  pain, 
not  always,  however,  in  the  hepatic  region,  but  in  different  parts  of  tlie 
abdomen,  enlargement  of  the  liver,  usually  downward,  and  tenderness 
over  the  liver.  If  in  addition  to  these  symptoms  a  tumor  is  detected 
apparently  connected  with  the  liver,  and  accompanied  by  fever  of  a  hectic, 
pyaemic,  or  intermittent  type,  with  sometimes  an  initial  chill  or  with 
irregular  daily  chills,  abscess  of  the  liver  is  to  be  strongly  suspected. 
Leucocytosis  is  present.  The  symptoms  are  at  times,  however,  very 
latent,  and  the  diagnosis  can  only  be  determined  by  aspiration. 


840  PEDIATRICS. 

The  duration  of  the  disease  is  apt  to  be  prolonged,  and  the  child 
gradually  emaciates  and  fails  in  strength. 

The  prognosis  varies  greatly,  as  there  are  so  many  conditions  as  to  the 
especial  cause  and  the  especial  locality  of  the  abscess  which  must  be  taken 
into  account  and  which  render  the  chances  of  recovery  more  or  less  un- 
certain. 

Treatment. — The  treatment  is  essentially  surgical.  Musser  reports 
twelve  recoveries  out  of  the  thirty-four  cases,  and  m  eleven  of  these 
aspiration  or  incision  or  both  were  employed. 

HYDATIDS.— BILIARY  CALCUU:.— NEW  GROWTHS. 
Ecliinococcus  cysts  and  biliary-  calculi  are  so  rare  in  early  life  that  they 
need  merely  be  mentioned  as  of  possible  occurrence.  Carcinoma,  ade- 
noma, and  sarcoma  and  lympho-sarcoma  of  the  liver  have  in  rare  in- 
stances been  met  with  in  early  life.  Tuberculosis  of  the  liver  has  been 
described  on  page  422.  Miiller  has  reported  a  case  of  cystic  liver  in  an  in- 
fant of  10  months,  which  weighed  1500  grammes  at  autopsy.  The  cysts 
were  shown  to  have  originated  in  newly  formed  bile-ducts.  Another  case 
is  reported  in  an  infant  seven  months  old. 

AMYLOID  LIVER. 

"When  amyloid  changes  are  present  in  the  liver,  other  organs,  such  as 
the  spleen,  kidneys,  and  intestme,  are  involved.  Amyloid  mfiltration  may 
occur  in  the  course  of  tuberculosis  when  there  is  chronic  disease  of  the 
bones  with  extensive  suppuration,  in  wasting  diseases,  and  in  hereditary 
syphilis.  A  very  prominent  symptom  in  this  condition  is  an  extreme  degree 
of  secondarj"  anaemia.  The  liver  is,  as  a  rule,  very  much  enlarged,  and 
commonly  more  so  than  m  any  of  the  other  hepatic  disturbances.  Its 
surface  is  smooth,  and  there  is  rarely  hepatic  tenderness  or  pain.  Ascites 
is  rare,  and  there  is  usually  no  icterus.  The  progress  of  the  disease  is 
slow. 

The  diagnosis  is  not  difficult  if  we  find  that  the  child  has  one  of  the 
diseases  which  have  just  been  mentioned  as  being  the  causes  of  amyloid 
changes.  The  skin  has  a  waxy  appearance.  The  spleen  is  enlarged, 
and  there  may  be  albuminuria  and  dropsy,  either  from  an  associated 
amyloid  condition  of  the  kidney  or  from  the  pressure  produced  by  the 
enlarged  liver. 

When  these  changes  occur  in  the  liver  the  prognosis  is  very  grave, 
and  there  is  no  treatment  which  will  be  of  more  than  temporary  benefit. 
The  treatment,  therefore,  is  removal,  if  possible,  of  the  cause,  such  as  a 
diseased  joint.  If  the  disease  is  the  result  of  syphilis,  anti-sypliilitic 
remedies  should  be  employed. 

Fig.  180  represents  a  boy  seven  and  three-quarter  years  old.  There  was  no  his- 
tory of  tuberculosis  in  his  family.      He  had  pertussis  when  he  was  one  and  a  quarter 


DISEASES   OF   THE   LIVER. 


841 


years  old,  and  measles  when  he  was  three  years  old.  He  seemed  well  and  strong  until 
he  was  about  seven  years  old,  when  he  became  listless  and  began  to  have  fever  and  to 
perspire  profusely.  Later  he  began  to  vomit  occasionally,  to  complain  of  headache, 
and  to  cough.  Although  he  evidently  lost  in  weight  he  was  not  especially  emaciated. 
His  entire  skin  was  extremely  pale  and  had  a  waxy  look,  which  was  apparently  not 
due  to  jaundice.  His  mucous  membranes  showed  much  anaemia.  His  tongue  was 
heavily  coated,  and  his  breath  was  offensive.  He  was  dull  and  apathetic.  The  cer- 
vical glands  were  enlarged  and  slightly  tender,  but  did  not  fluctuate.  The  glands  were 
moderately  enlarged  in  the  axillae  and  groins.  The  percussion  of  the  right  lung,  espe- 
cially at  the  apex,  was  dull,  and  there  were  numerous  rales.  The  area  of  cardiac  dul- 
ness  was  not  enlarged,  but  there  was  a  slight  systolic  murmur  at  the  apex.     The  spleen 

Tig.    180 


Amyloid  liver.    Pulmonary  tuberculosis.    Male,  7%  years  old. 


was  slightly  enlarged.  The  edge  of  the  liver  could  be  felt  below  the  line  of  the  um- 
bilicus. The  area  of  hepatic  dulness  was  increased,  as  is  represented  by  the  broken  line 
in  the  figure.  There  was  no  hepatic  tenderness,  and  the  child  did  not  complain  of 
pain.  The  lower  part  of  the  abdomen  was  dull  on  percussion  as  high  as  the  line  which 
is  drawn  under  the  umbilicus.  This  was  due  to  a  slight  amount  of  ascites.  The  legs 
were  swollen.  The  urine  had  a  specific  gravity  of  1010,  and  contained  a  slight  trace 
of  albumin,  an  occasional  hyaline  cast,  and  renal  epithelium.  The  temperature  had 
varied  from  37.2°  to  39.4°  and  40.5°  C.  (99°  to  103°  and  105°  F.).  The  increased 
size  of  the  liver  was  probably  due  to  amyloid  infiltration,  following  what  was  supposed 
to  be  pulmonary  tuberculosis. 

A  few  days  later  the  child  grew  rapidly  weaker,  and  died  of  exhaustion.  An 
autopsy  was  not  obtained. 

INTERSTITIAL  HEPATITIS.— CIRRHOSIS. 

Interstitial  hepatitis  may  be  a  lesion  of  a  number  of  systemic  diseases, 
especially  of  syphilis,  but  also  of  tuberculosis.  The  disease,  however, 
may  apparently  occur  without  disease  of  any  other  organ.  In  infants 
cirrhosis  of  the  liver  is  almost  invariably  of  syphilitic  origin. 

Regarding  cirrhosis,  in  connection  with  congenital  obstruction  of  the 
bile-ducts,  Morse  gives  the  following  explanation  as  to  the  etiology.     Irri- 


842  PEDIATRICS. 

tant  substances  may  pass  through  the  placenta  to  the  fetus  and  reach  the 
hver  directly  or  indirectly  through  the  general  circulation  and  so  produce 
the  conditions  necessary  for  a  mixed  cirrhosis.  The  cholangitis  then 
descends  to  the  larger  ducts.  Stenosis  and  obliteration  readily  follow, 
because  of  the  extremely  small  size  of  their  lumen  at  this  time. 

Additional  points  in  favor  of  primary  cirrhosis  are  :  (1)  The  constant 
occurrence  of  cirrhosis  in  obstruction  of  bile-ducts  in  infants,  compared 
with  its  rarity  after  obstruction  of  the  larger  ducts  in  adults.  (2)  The 
large  size  of  the  liver,  which  is  usually  small  when  due  to  obstruction  in 
later  life.  (3)  The  enlargement  of  the  spleen,  which  does  not  occur  in 
uncomplicated  bihary  obstruction.  It  seems  reasonable  to  suppose,  there- 
fore, that  the  disease  is  due  to  irritants  derived  from  the  mother,  which 
cause  a  cirrhosis  and  cholangitis,  the  cholangitis  descending  and  obliterat- 
ing the  larger  ducts. 

A  certain  number  of  cases  seem  to  have  followed  scarlet  fever  and 
measles.  Alcohol  is  sometimes  an  etiological  factor  in  infancy  and  early 
childhood.  When  the  disease  is  caused  by  alcohol  the  pathological  condi- 
tion is,  as  a  rule,  atrophy. 

Interstitial  hepatitis  as  it  occurs  in  childhood  may  be  atrophic  or  hyjier- 
trojjhic.  The  general  symptomatology  differs  but  little  from  that  of  the 
adult.  In  the  beginning  the  symptoms  are  very  apt  to  be  confounded 
with  those  of  simple  congestion  arising  from  digestive  disturbances.  There 
may  be  abdominal  pain,  slightly  augmented  by  pressure.  Diarrhoea  and 
constipation  alternate.  There  are  usuahy  ascites  and  slight  jaundice,  and 
at  times  dilatation  of  the  subcutaneous  abdominal  veins.  Stigmata  com- 
posed of  collections  of  dilated  minute  veins  are  sometimes  observed  on 
the  face.  The  temperature  is  irregular.  As  a  rule,  it  is  not  much  height- 
ened, and,  in  fact,  is  often  subnormal.  When  the  hepatitis  is  not  de- 
pendent on  disease  elsewhere,  and  is  not  due  to  alcohol,  there  are  no 
characteristic  symptoms  beyond  the  enlargement  of  the  liver.  In  this 
form  the  ascites  is  usually  small  in  amount,  and  the  diagnosis  can  be  made 
only  by  eliminating  the  other  forms  of  enlargement.  It  is  commonly 
spoken  of  as  hypertrophic  cirrhosis.  Its  prognosis  is  more  favorable  than 
that  of  the  cirrhosis  just  described.  The  enlargement  is  not  prominent, 
and  the  symptoms  are  the  same  as  in  the  adult,  the  ascites  being 
especially  marked. 

Prognosis. — The  prognosis  in  this  class  of  cases  is  bad,  as  the  progress 
of  the  disease  is  usually  rather  rapid. 

Treatment. — The  treatment  of  cirrhosis  of  the  liver  is  symptomatic. 
Owing  to  the  prominence  of  syphilis  as  a  cause  of  cirrhosis  in  infants, 
anti-syphilitic  treatment  should  always  be  tried,  even  in  the  absence  of 
other  signs  of  congenital  syphilis.  It  should  be  pushed  vigorously  and 
for  a  considerable  period. 

Fig.  181  represents  a  girl  eighteen  months  old.  There  was  no  history  of  syphilis 
or  of  tuberculosis.     She  had  pertussis  when  she  was  ten  months  old,  and  the  cough 


DISEASES   OF   THE  PANCREAS. 


843 


lasted  for  several  months.  Slie  had  never  been  given  alcohol  in  any  form.  She  was 
well  until  she  was  fifteen  months  old,  when  she  began  to  complain  of  pain  in  the 
abdomen  and  to  become  pale.  Before  entering  the  hospital  she  had  diarrhoea,  and 
her  abdomen  was  swollen.  On  entering  the  hospital  and  being  placed  on  a  proper 
diet,  the  diarrhoea  ceased,  but  the  swelling  of  the  abdomen  increased.  She  was  not 
especially  thin,  but  was  pale.  The  abdomen  was  much  enlarged.  The  edge  of  the 
liver  could  be  felt  nearly  as  low  as  the  line  of  the  umbilicus.  The  area  of  dulness  on 
percussion  is  marked  by  black  lines.     The  lower  one  shows  the  notch  between  the 

Pig.   181. 


Hypertrophic  cirrhosis.     Female,  18  months  old. 

right  and  the  left  lobe,  which  was  distinct  and  easily  palpable.  There  was  no  especial 
tenderness  on  pressure.  The  spleen  was  slightly  enlarged.  In  the  lower  part  of  the 
abdomen  there  was  a  moderate  amount  of  dulness  and  fluctuation,  showing  the  pres- 
ence of  fluid.  There  were  no  glandular  swellings.  The  heart  was  normal,  but  was 
pushed  up  somewhat  by  the  abdominal  distention. 

The  child  improved  in  its  general  health  while  in  the  hospital,  and  had  a  fair  appe- 
tite. Physical  examination  showed  the  presence  of  no  other  disease.  Without  an 
autopsy,  however,  the  diagnosis  was  necessarily  held  in  abeyance. 

The  child  remained  in  the  hospital  for  a  few  weeks,  and  improved  in  its  general 
health  so  that  it  seemed  quite  bright.  The  ascites  did  not  increase  in  amount,  but  the 
liver  remained  enlarged.  The  child  was  eventually  taken  away  from  the  hospital,  and 
its  subsequent  history  could  not  be  obtained. 


DISEASES  OF  THE  PANCREAS. 

Diseases  of  the  pancreas  are  practically  unknown  in  infancy  and  child- 
hood, with  the  exception  of  the  general  tissue-changes  which  may  be  met 


g44  PEDIATRICS. 

with  in  syphilis,  and  which  have  already  been  described.     New  growths 
of  a  malignant  nature  have  been  reported. 


DISEASES  OF  THE  SPLEEN. 

The  spleen  may  be  involved  in  tuberculosis,  and  may  show  amyloid 
changes  in  connection  with  other  organs.  It  is  frequently  enlarged  in  the 
course  of  a  number  of  diseases  which  have  been  described  elsewhere,  but 
there  are  no  primary  diseases  of  the  spleen. 

DISEASES  OF  THE  PERITONEUM. 

Diseases  of  the  peritoneum  may  be  of  non-infectious  or  infectious 
origin. 

The  non-infectious  diseases  are  mostly  represented  by  new  growths. 
These  may  be  of  a  malignant  nature,  such  as  carcinoma  and  sarcoma,  or 
they  may  be  lipomata  or  of  a  cystic  character.  Tumors  of  the  omentum 
are  rare,  but  cysts  and  hydatids  may  occur  in  this  region.  The  differen- 
tial diagnosis  of  these  various  forms  of  peritoneal  and  omental  growths 
can  scarcely  be  made  during  life.     The  treatment  is  essentially  surgical. 

The  infectious  diseases  of  the  peritoneum  are  represented  by  peritonitis. 

ACUTE  PERITONTnS. 

Etiology. — Acute  infection  of  the  peritoneum  may  be  primary  or  sec- 
ondary.    It  is  a  condition  of  great  importance  in  infancy  and  early  life. 

Infants  and  children  of  any  age  may  be  attacked.  The  disease  may 
occur  in  the  course  of  tuberculosis,  or  any  infectious  disease,  of  syphilis, 
and,  most  frec{uently  of  all,  of  appendicitis.  The  disease  in  any  of  the 
above  forms  is  exceedingly  rare  between  the  ages  of  six  weeks  and  two 
years. 

A  large  variety  of  micro-organisms  are  found  in  connection  with  acute 
peritonitis.  The  colon  bacillus  is  the  most  frequent  cause.  Streptococci, 
staphylococci,  and  pneumococci  are  sometimes  found  either  alone  or  in 
mixed  cultures.  In  the  rare  instances  of  perforation  of  typhoid  ulcers 
typhoid  bacilli  may  be  cultivated  from  the  abdominah  fluid  in  conjunction 
with  the  colon  bacillus  and  other  intestinal  micro-organisms.  Tubercular 
peritonitis  has  been  described  on  page  396. 

Perforation  of  some  viscus  mto  the  peritoneal  cavity  is  the  underlying 
cause  of  many  cases  of  peritonitis.  Such  an  accident  may  occur  from 
intestinal  ulcers,  from  abscesses  and  cysts  of  the  liver,  gall-bladder,  spleen, 
kidney,  lymph-glands,  and  appendix,  and  from  strangulated  hernise  and 
intussusteptions. 

Peritonitis  may  also  be  set  up  by  extension  from  neighboring  inflamma- 
tory processes,  even  when  no  direct  communication  has  been  made  with 
the  peritoneal  cavity  by  means  of  perforation. 


DISEASES   OF   THE   PERITONEUM.  845 

Traumatic  peritonitis  may  develop  from  blows,  punctured  wounds,  and 
septic  infection  from  surgical  operations. 

Pathological  Anatomy. — The  lesions  in  acute  peritonitis  are  repre- 
sented by  reddening  and.  loss  of  the  nonnal  glistening  appearance  of  the 
peritoneum,  soon  followed  by  an  exudation  varymg  from  a  thin  serum 
\\\i\\  a  small  number  of  white  and  red  blood-corpuscles  to  a  thick,  fibrino- 
purulent  exudate.  The  character  of  the  pathological  processes  have 
been  more  fully  described  under  the  various  forms  of  appendicitis  with 
peritonitis  on  page  829.  In  the  peritonitis  of  the  new-born  the  charac- 
teristic lesions  are  apt  to  be  in  the  umbilical  region,  and  are  not  infre-- 
quently  associated  with  lesions  of  a  general  septicaemia. 

Symptoms. — The  symptoms  of  acute  peritonitis  vary  according  as  the 
process  is  general  or  localized.  The  localized  form  of  peritonitis  corre- 
sponds in  its  symptoms  to  what  has  already  been  descrDDed  in  speaking 
of  appendicitis,  which  is  its  most  frequent  cause.  In  general  peritonitis 
the  symptoms  in  infants  are  often  obscure.  In  children  the  symptoms 
are  usually  pronounced  and  characteristic.  The  child  is  attacked  with 
abdominal  pain  and  with  general  abdominal  tenderness.  The  abdomen 
becomes  distended  and  tympanitic,  and  the  child  assumes  the  position 
which  will  most  relax  the  abdommal  walls, — that  is,  with  the  thighs  flexed 
and  the  knees  bent.  Vomiting  is  very  apt  to  be  present,  and  is  augmented 
when  food  is  given.  The  bowels  are  often  constipated,  although  at  times 
there  may  be  diarrhoea.  The  temperature  is  usually  high,  38.3°  to  40.5° 
C.  (101°  to  105°  F.) ;  in  some  cases,  however,  the  temperature  may  be 
normal  or  subnormal.  The  pulse  is  small  and  rapid.  The  respirations 
are  not  only  accelerated,  but  also  superficial,  as  deep  respiration  causes 
pain.  The  face  has  an  anxious  expression,  and  shows  great  suffering. 
When  recovery  takes  place,  these  symptoms  gradually  subside  after  a  few 
days,  the  tenderness,  pain,  and  tympanites  disappear,  and  the  cliild's  face 
assumes  a  tranquil  look.  When  improvement  does  not  take  place,  the 
pulse  becomes  weaker  and  more  rapid,  the  breathing  more  superficial 
and  more  frequent,  there  is  chilling  of  the  extremities,  and  the  child  dies 
usually  within  a  week.  Leucocytosis  is  generally  marked  unless  the 
severity  of  the  infection  is  so  great  as  to  render  a  reaction  impossible. 

Peritonitis  of  the  New-Born. — This  form  generally  appears  within  the 
first  two  or  three  days  of  life,  rarely  later  than  the  first  week.  The  onset 
is  sudden,  with  vomiting,  diarrhoea,  pain,  distention  of  the  abdomen,  and 
tenderness.  The  temperature  is  very  high,  40°  C.  to  41°  C.  (104°  F.  to 
106°  F.).  In  a  case  reported  by  Quinquand  it  reached  42.5°  C.  (108.5° 
F.).  Emaciation  is  rapid  and  the  cachexia  is  extreme.  Hydrocele,  gen- 
erally of  the  right  side,  with  oedema  of  the  scrotum,  frequently  develops. 
Septicaemia  and  pyaemia  may  occur  as  complications.  Death  takes  place 
in  four  or  five  days. 

Acute  Pneumococcus  Peritonitis, — Peritonitis  may  be  due  to  a 
primary  idiopathic  infection  by  the  pneumococcus,  or  to  a  secondary  in- 


846  PEDIATRICS 

fection  from  the  same  organism  in  connection  with  pnemnonia,  pleurisy, 
or  meningitis.  Netter  has  reported  a  case  of  pneumococcus  meningitis 
with  pneumococcus  peritonitis  in  an  infant  three  or  four  days  old.  Accord- 
ing to  Comby,  primary  pneumococcus  peritonitis  is  more  frequent  in  chil- 
dren than  in  adults,  and  is  most  common  between  the  ages  of  three  and 
twelve  years.  In  Brun's  series  of  cases  it  was  nearly  four  times  more 
frequent  in  girls  than  in  boys. 

Dieulafoy  describes  pneumococcus  peritonitis  as  a  special  clinical 
form,  which  can  sometimes  be  diagnosticated  by  the  character  of  the 
symptoms. 

Symptoms. — The  onset  is  sudden,  with  intense  abdominal  pain,  diar- 
rhoea, and  fsecal  vomiting.  The  temperature  rises  to  39°  to  40°  C.  (102.2° 
to  104°  F.),  and  there  may  be  delirium.  A  remission  of  some  of  these 
symptoms  then  ensues,  the  pain  subsides,  diarrhoea  and  distention  per- 
sist, and  the  picture  is  more  like  that  of  typhoid  fever.  At  the  end  of 
about  eight  days  the  temperature  falls,  sometimes  as  abruptly  as  in 
pneumococcus  pneumonia.  The  disease  then  passes  into  another  stage, 
which  resembles  tubercular  peritonitis.  There  is  emaciation,  cachexia, 
pinched  features,  sunken  eyes,  and  a  large  and  tender  abdomen,  usually 
with  signs  of  fluid.  The  fluid,  which  is  purulent,  is  not  very  movable,  but 
shows  a  strong  tendency  to  become  encysted.  The  process  may  go  on 
for  several  weeks  and  finally  end  in  spontaneous  evacuation  of  the  pus. 
While  recovery  may  take  place  by  natural  means,  the  danger  of  secondary 
infection  and  death  from  exhaustion  is  so  great  that  early  surgical  inter- 
ference is  indicated,  as  under  favorable  conditions  a  good  proportion  of 
the  operative  cases  recover. 

Prognosis. — The  prognosis  in  acute  peritonitis  is  always  grave.  It  de- 
pends largely  upon  the  virulence  of  the  exciting  cause,  upon  an  early 
diagnosis,  and  upon  prompt  and  skilful  surgical  treatment. 

Treatment. — The  treatment  is  essentially  the  same  as  has  been  de- 
scribed under  appendicitis  with  peritonitis  on  page  831. 

The  following  case  illustrates  acute  peritonitis  : 

An  infant,  nineteen  months  old,  previously  apparently  healthy,  was  attacked  with 
vomiting  and  diarrhoea.  On  the  following  day  the  face  was  pale,  the  alae  nasi  were 
working  slightly,  the  respirations  were  36,  and  the  temperature  was  39.4°  C.  (103°  F.). 
The  respirations  gradually  increased  to  74,  and  the  temperature  rose  to  40.3°  C.  (104.6° 
F.).  The  abdomen  became  very  much  distended  and  tender,  and  the  face  pinched 
and  anxious.  On  the  evening  of  the  second  day  from  the  onset  of  the  disease  the 
temperature  rose  to  41.1°  C.  (106°  F.),  the  infant  became  very  restless,  the  pupils 
were  contracted,  and  death  took  place  a  few  hours  later. 

The  autopsy  showed  that  the  heart  and  lungs  were  normal.  The  spleen  was  en- 
larged, and  was  covered  with  a  fibrinous  exudation.  The  kidneys  were  pale,  and  normal 
in  size.  The  liver  was  covered  with  flakes  of  lymph  of  recent  formation,  and  on  sec- 
tion showed  the  acini  to  be  red  and  their  periphery  yellowish  and  opaque.  The  mes- 
enteric lym.ph-nodes  were  slightly  enlarged,  and  the  smaller  ones  were  translucent  on 
section  and  presented  evidence  of  hyperplasia.  A  small  pocket  of  the  larger  nodes 
was  found  to  have  become  cheesy  in  the  central  portions,  and  in  two  of  these  the  pro- 


DISEASES    OF   THE    PERITONEUM.  847 

cess  had  extended  through  the  substance  of  the  gland  and  had  broken  through  its  peri- 
toneal covering.  About  these  points  of  rupture  there  was  a  small  zone  of  reactive 
inflammation. 

The  anatomical  diagnosis  was  acute  general  peritonitis,  which  from  an  absence 
of  any  other  source,  must  be  considered  to  haA^e  been  caused  by  the  rupture  of  the 
cheesy,  degenerated  mesenteric  nodes. 

In  this  case  the  high  temperature  and  the  distended  abdomen  rendered  the  diag- 
nosis comparatively  clear.  The  case  is  important  on  account  of  the  cause,  for  there 
is  seldom  any  noticeable  enlargement  of  the  mesenteric  nodes  under  the  age  of  three 
years,  and  these  nodes  seldom  soften,  but  either  retrograde  or  harden  from  calcification. 

CHRONIC  PERITONITIS. 

By  far  the  most  common  cause  for  chronic  peritonitis  witli  ascites  is 
tuberculosis,  which  has  been  described  on  page  396. 

When  an  acute  peritonitis  is  localized,  the  inflammatory  process  may 
subside,  the  fibrino-purulent  exudation  may  become  organized,  and  the 
result  be  fibrous  adhesions  binding  the  coils  of  the  intestine  closely  to- 
gether and  to  the  abdominal  wall. 

A  form  known  as  congenital  j^eritonitis  occurs,  but  is  of  pathological 
rather  than  of  clinical  interest.  In  this  form  the  fibrous  adhesions  are 
found  in  infants  who  have  died  within  a  few  hours  after  birth.  It  is  con- 
sidered a  peritonitis  of  intra-uterine  development,  possibly  through  the 
placenta  from  an  intra-uterine  peritonitis  in  the  mother. 


DIVISION    XIV. 

DISEASES  OF  THE  KIDNEYS,  BLADDER,  AND  GENITAL 

ORGANS. 


DISEASES  OF  THE  KIDNEYS. 
Diseases  of  the  kidneys  may  be  congenital  or  acquired. 

CONGENITAL  DISEASES. 
The  congenital  abnormahties,  such  as  congenital  cystic  kidney,  absence 
of  one  kidney,  hypertrophy  of  the  reniainmg  kidney  when  one  is  absent, 
anomalous  shapes  of  the  kidney,  and  malpositions  of  the  ureters,  are 
important,  but  are  of  surgical  rather  than  of  medical  interest.  The  lobu- 
lated  kidney,  already  described  as  a  normal  condition  in  intra-uterme  life, 
may  to  a  greater  or  less  degree  continue  into  infancy  and  childhood,  but 
has  no  pathological  significance.  Movable  kidneys  are  rare  in  early  life, 
but  have  been  reported. 

ACQUIRED    DISEASES. 

Renal  disease  as  a  primary  affection  in  infancy  and  cliildhood  has 
been  considered  rare,  but  this  view  has  been  modified  by  later  investi- 
gations, which  have  shown  that  nephritis  is  not  uncommon  in  cases  of 
general  infection.     Secondary  renal  lesions  are  comparatively  common. 

The  systematic  examination  of  the  urine  in  children  in  connection 
with  the  different  pathological  lesions  of  the  kidney  has  not  yet  been 
made  to  such  an  extent  that  we  can  invariably  differentiate  the  especial 
type  of  lesion  by  the  character  of  the  urine.  Clinically,  the  diseases  of 
the  kidney,  as  differentiated  by  the  urinary  examination  in  infancy  and 
early  childhood,  are  less  varied  than  in  adults.  They  are  represented 
chiefly  by  acute  degeneration  and  the  mild  and  severe  forms  of  acute 
nephritis  following  scarlet  fever  especially  and  other  of  the  acute  infectious 
diseases. 

General  Etiology  axd  Pathology. — According  to  Councilman,  to  whom 
we  are  indebted  for  much  information  on  this  subject,  the  acquired  diseases 
of  the  kidney  in  childhood  show  considerable  differences  from  the  renal 
diseases  of  the  adult.  In  childhood  there  is  a  greater  liability  to  those 
acute  affections,  such  as  scarlet  fever,  measles,  and  diphtheria,  in  the 
848 


DISEASES   OF   THE   KIDNEYS.  849 

course  of  which  nephritis  is  apt  to  appear.  Children  under  the  age  of  fifteen 
years  are  less  subject  to  many  pathological  conditions,  such  as  disorders 
of  the  circulation,  which  in  the  adult  frequently  lead  to  chronic  lesions 
of  the  kidney.  Children  do  not  usually  have  those  disorders  of  the 
circulation  which  result  in  granular  kidney,  for  lesions  of  the  arteries, 
especially  the  condition  known  as  arterio-sclerosis,  do  not  commonly 
occur  in  childhood.  While  it  is  true  that  typical  examples  of  the  small 
granular  kidney  are  sometimes  met  with  in  children,  these  lesions  of  the 
kidney  are  primary,  and  the  lesions  of  the  circulatory  system  are 
secondary  and  dependent  on  the  renal  lesions.  A  part  of  the  chronic 
diseases  of  the  kidney  in  the  adult  is  without  doubt  to  be  referred  to  the 
continuous  action  on  the  kidney  of  slight  pathological  conditions,  an 
action  from  which  the  child's  age  protects  it.  One  pathological  lesion 
not  perfectly  recovered  from,  moreover,  makes  the  kidney  more  prone  to 
disease,  and  a  greater  effect  will  be  produced  a  second  time  by  the  same 
cause,  and  chronic  disease  may  result.  In  the  kidney  of  the  adult,  with 
the  advance  of  years  there  is  a  gradual  decline  in  the  power  of  regen- 
eration, and  slight  troubles  are  not  readily  recovered  from.  The  kidney 
of  the  child,  on  the  other  hand,  is  an  organ  which  possesses  great  power 
of  gro^vth  and  regeneration.  For  this  reason  a  condition  which  in  the 
adult  organ  is  either  not  recovered  from  at  all,  or  lays  the  foundation  for 
chronic  disease,  may  in  childhood  result  in  complete  recovery.  Again,  the 
child  is  not  exposed  to  certain  conditions  which  are  productive  of  chronic 
lesions,  or  which  may  lay  the  foundation  for  them.  Among  these  may  be 
mentioned  alcoholism  and  excesses  of  various  sorts.  Many  cases  of 
nephritis  in  the  adult  are  to  be  referred  to  causes  acting  not  through  the 
blood,  but  through  the  urinary  tract.  The  child,  on  the  other  hand,  is  not 
exposed  to  the  dangers  arising  from  hydronephrosis  and  pyelonephritis, 
except  to  a  very  limited  degree.  Although  the  causes  of  renal  disease 
are  less  numerous  and  less  common  in  children  than  in  adults,  yet  when 
the  same  etiological  factor  is  present  the  same  morbid  condition  is  pro- 
duced in  the  kidney.  The  various  cachectic  conditions  will  lead  to  amy- 
loid infiltration  in  the  child  as  they  do  in  the  adult,  and  amyloid  in- 
filtration of  the  kidney  makes  up  by  far  the  larger  part  of  the  chronic 
cases  of  albuminuria  in  children.  We  may  also  meet  with  certain  chronic 
lesions  in  the  child's  kidney,  such  as  are  seen  in  tuberculosis,  and  these 
may  lead  to  albuminuria  and  to  nephritis. 

The  acute  diseases  of  the  kidney  may  either  lead  to  recovery  or  may 
of  themselves  prove  fatal.  They  are  not  to  be  referred  to  the  contin- 
uous action  of  the  poison  of  the  acute  disease,  but  to  the  effect  on  the 
kidney  of  the  lesions  produced  by  the  inflammatory  process.  An  example 
of  this  is  the  condition  of  chronic  nephritis  after  scarlet  fever,  in  which  the 
acute  lesions  gradually  pass  into  the  chronic.  These  chronic  lesions  are 
to  be  attributed  to  the  disorders  in  the  circulation  of  the  organ  brought 
about  by  the  destruction  of  the  glomeruh. 

54 


850  PEDIATRICS. 

Cabot's  critical  study  of  urines  of  adults  in  comparison  with  the  ana- 
tomic diagnosis,  as  determined  by  autopsies,  shows  that  much  less  reliance 
than  was  formerly  supposed  can  be  placed  upon  the  examination  of  the 
urine  alone,  in  diagnosticating  the  different  forms  of  renal  disease.  The 
same  conclusion  probably  is  ecjually  warranted  in  diseases  of  the  kidney 
in  children.  Our  descriptions,  therefore,  in  the  light  of  these  investiga- 
tions, are  necessarily  incomplete  and  inexact,  but  they  are  not  useless. 
Cases  undoubtedly  occur  which  correspond  to  the  types  descrilDed,  but 
one  is  likely  to  overlook  the  pathologic  conditions  when  the  urine  is 
atypical,  ]\Iany  cases  of  acute  glomerular  nephritis  exist  which  cannot  be 
recognized  by  present  methods  of  examination.  The  possibility  of  a  cor- 
rect diagnosis  of  chronic  glomerular  nephritis  from  the  clinical  symptoms 
and  urinary  examinations  is  much  greater  than  in  the  acute  cases.  The 
amount  of  albumin  and  character  of  the  casts  is  especially  misleading. 
The  most  reliaJDle  data,  according  to  Cabot,  are  the  twenty-four  hour 
quantity,  the  specific  -gravity  and  the  color  of  the  urine.  Cryoscopy  and 
other  methods  of  determining  renal  excretions  have  not  proved  suf- 
ficiently accurate  and  practicable  to  add  much  value  to  the  older  methods 
of  examination. 

General  Symptomatology. — The  general  symptoms  connected  with  the 
various  forms  of  nephritis  are  so  similar  that  it  will  be  less  confusing  to 
mention  first  the  common  symptoms  which  may  occur  in  any  of  the 
forms  of  nephritis,  and  then  to  describe  the  etiology,  pathology,  and 
urinary  examination  of  the  different  forms. 

One  of  the  most  common  signs  in  nephritis  is  (sdema,  which  occurs 
frequently  in  acute  nephritis  and  in  subacute  and  chronic  glomerular 
nephritis.  The  oedema  generally  appears  first  in  the  eyelids,  and  then  in 
the  hands  and  feet.  There  may  be  general  anasarca.  Not  infrequently, 
however,  oedema  is  absent  or  not  marked.  Nausea  and  vomiting  are  not 
infrequent  in  the  beginning  of  the  disease',  and  in  some  cases  are,  perhaps, 
due  to  the  heightened  temperature.  It  may  occur  later  in  the  disease  as 
a  symptom  of  urgemic  poisoning.  In  such  cases  there  is  marked  diminu- 
/^  ^ion  in  the  amount  of  the  urine,  or  even  suppression.  A  marked  second- 
ary anaemia  giving  a  peculiar  dull  white  color  to  the  skin  is  commonly  • 
seen  in  subacute  and  chronic  glomerular  nephritis,  and  is  c{uite  striking. 
In  acute  nephritis  fever  is  often  present  to  a  greater  or  less  extent,  but  is 
a  variable  symptom.  Lack  of  appetite,  and  weakness,  are  common  in 
both  acute  and  chronic  nephritis.  Headache  is  a  variable  symptom.  It 
is  a  frequent  symptom  of  uraemia,  and  sometimes  the  only  one.  Restless- 
ness and  insomnia  are  often  met  with,  and  attacks  of  dyspnoea  may 
occur.  Amaurosis  may  occur  as  the  result  of  albuminuric  retinitis,  or  it 
may  be  a  functional  symptom  of  the  uraemic  poisoning  and  disappear  later 
if  the  patient  recovers.  Hypertrophy  of  the  left  ventricle  with  a  pulse  of 
high  tension  is  apt  to  occur  in  interstitial  and  chronic  parenchymatous 
nephritis.     Both  diseases  are,  however,  very   uncommon   in   childhood. 


DISEASES   OF   THE   KIDNEYS.  851 

In  acute  nephritis  following  scarlet  fever  dilatation  and  moderate  hyper- 
trophy of  the  left  ventricle  are  not  uncommon.  Transudation  into  the 
serous  cavities  has  been  reported  in  a  number  of  cases,  as  has  also 
CEdema  of  the  larynx. 

In  all  cases  of  nephritis  the  amount  of  total  solids  excreted  during  the 
twenty-four  hours  should  be  carefully  estimated  from  time  to  time,  as  a 
decrease  in  the  solids  always  suggests  a  pathological  condition,  and  a 
return  to  the  normal  amount  is  usually  indicative  of  recovery  unless  there 
is  a  complication  with  some  other  disease.  Any  interference  with  metabo- 
lism, however,  whether  in  the  liver  or  in  the  lung,  may  diminish  the 
amount  of  solids  in  the  urine.  In  children  during  convalescence  from 
acute  nephritis  the  solids  returns  to  or  exceeds  the  normal  amount,  while 
in  chronic  nephritis  it  is  always  diminished,  as  it  is  in  adults.  A  sudden 
and  excessive  diminution  of  the  solids  in  acute  nephritis  is  suggestive  of 
uraemia.  In  acute  and  chronic  nephritis  the  chlorides  are  diminished 
when  an  effusion  such  as  ascites  is  increasing,  and  gradually  return  to  the 
normal  amount  as  the  effusion  is  absorbed. 

In  any  attempt  to  estimate  the  functional  activity  of  the  kidney,  either 
as  regards  the  quantity  of  urine  or  the  amount  of  solids  excreted,  it  is 
very  desirable  to  know  the  amount  passed  in  twenty-four  hours.  This  is 
practically  impossible  in  infants  and  very  young  children,  in  whom  it  is 
often  difficult  to  obtain  even  a  single  specimen.  Various  methods  have 
been  devised  for  collecting  the  urine  in  infants.  The  most  simple  and 
effective  is  a  cotton  ring  large  enough  to  enclose  the  buttocks  and  genitals. 
The  ring  is  lined  with  sheet  rubber,  and  the  infant  (the  napkin  having  been 
removed)  rests  upon  it  comfortably,  and  the  urine  can  be  collected  as  in 
a  bed-pan.  In  boys,  a  small  bottle  wdth  a  neck  large  enough  to  hold  the 
penis  can  be  held  in  place  by  strips  of  surgeon's  plaster  attached  to  the 
bottle  and  abdominal  wall.  In  girl  babies,  catheterization  is  easily  per- 
formed and  the  urine  can  be  readily  obtained  in  this  way  in  important  cases. 

ANURIA. 

Anuria  is  an  arrest  of  the  secretion  of  urine.  It  must  be  distinguished 
from  retention  of  urine  in  the  bladder,  from  the  scanty  urine  passed  when 
liquids  are  withheld  or  refused  in  sickness,  and  from  diminished  secretion 
dependent  upon  a  profuse  watery  diarrhoea.  Total  suppression  of  urine 
may  occur  in  the  intense  congestion  of  acute  nephritis,  in  poisoning  by 
lead,  phosphorus,  or  turpentine,  or  after  severe  injuries  or  operations. 

Anuria  in  the  new-born  may  be  due  to  malformation  of  the  urinary 
tract  or  to  uric  acid  infarction.  Other  cases  in  infants  are  evidently  of 
nervous  origin,  and  may  last  for  twenty-four  or  thirty-six  hours  without 
other  symptoms.  Hysterical  anuria  may  occur  in  older  children.  Charcot 
reports  a  case  lasting  for  eleven  days. 

Treatment. — The  obstructive  cases  demand  operation.  In  non-ob- 
structive cases  the  treatment  is  usually  simple  and  satisfactory.     Sweet 


852  PEDIATRICS. 

spirits  of  nitre  or  citrate  of  potash  given  with  plenty  of  water  will  usually 
relieve  the  condition.  Hot  applications  over  the  kidney  may  be  used,  or 
large  hot  irrigations  of  the  colon  with  salt  solution,  or  in  extreme  cases 
the  subcutaneous  injection  of  salt  solution. 

PHYSIOLOGICAI.   ALBUMTNURIA. 

This  condition  is  not  infrequent,  and  may  occur  at  any  period  of 
infancy  and  childhood,  but  is  most  common  between  the  fifth  year  and 
puberty.  It  is  more  common  in  boys  than  in  girls.  The  amount  of  albu- 
min present  is,  as  a  rule,  less  than  one-twelfth  per  cent.,  and  is  sometimes 
associated  with  temporarj^  glycosuria.  It  is  not  present  in  every  micturi- 
tion, and  in  many  cases  seems  to  depend  upon  over-exercise,  cold  bathing, 
or  a  highly  nitrogenous  diet.  The  albumin  is  rarely  present  in  the  urine 
which  is  passed  in  the  morning  immediately  after  rising,  and  this  is  an  im- 
portant point  in  differentiating  physiological  albummuria  from  periodic 
albuminuria  due  to  pathological  causes,  such  as  uric  acid.  The  presence 
of  blood-corpuscles  or  abnormal  elements  m  any  amount  from  the  kidney 
shows  that  there  is  a  pathological  condition.  The  children  who  have 
this  physiological  albuminuria  often  seem  to  be  in  good  health,  but  some- 
times they  are  rather  delicate.  The  diagnosis  can  be  made  only  by  re- 
peated examinations  of  the  urine  passed  at  different  times  in  the  day,  and 
by  observing  the  etfect  of  exercise  and  diet  upon  it.  An  occasional  hya- 
line cast  and  albumin  as  high  as  one-fourth  per  cent,  for  short  intervals 
may  be  present.  The  albumin  often  disappears  for  a  time  and  returns 
again.  Albumin  and  hyaline  casts  in  the  first  few  days  of  life  are  of 
little  significance. 

Albuminuria  of  Adolescence. — One  form  of  physiological  albumi- 
nuria is  that  which  has  been  called  the  albuminuria  of  adolescence.  At 
puberty  there  appears  to  be  a  disturbance  of  the  equilibrium  of  the  renal 
circulation,  occurring  so  frequently,  and  presenting  so  distinctively  the 
characteristics  of  a  simple  hyperaemia,  that  we  are  justified  in  looking 
upon  it  as  a  physiological  rather  than  as  a  pathological  condition. 
~~  This  physiological  congestion  of  the  kidney  is  probably  closely  con- 
nected with  the  development  and  increased  activity  of  the  uterme  circu- 
lation in  the  female,  and  with  the  prostatic  and  genital  blood-supply  in 
the  male.  The  importance  not  only  of  knowing  that  such  a  condition 
exists  at  puberty,  but  also  of  bearing  it  in  mind  when  we  are  called  to 
treat  children  who  are  on  the  border-line  between  cliildhood  and  adoles- 
cence, is  too  little  recognized,  and  this  want  of  recognition  often  leads  to 
unfortunate  mistakes. 

Prognosis. — The  prognosis  in  these  cases  of  physiological  albuminuria 
is,  as  a  rule,  good  ;  but  although  we  know  of  no  cases  in  which  the  condi- 
tion terminated  in  nephritis,  yet  the  prognosis  should  be  guarded. 

Treatment. — The  treatment  is  to  regulate  the  diet,  exercise,  and  gen- 
eral hygiene  carefully.     If  the  children  are  anaemic,  iron  is  indicated. 


DISEASES    OF   THE    KIDNEYS.  853 

The  following  is  one  of  a  number  of  cases  of  albuminuria  of  adoles- 
cence which  have  come  under  my  notice  : 

A  girl,  thirteen  years  old,  was  brought  to  me  for  advice  with  the  following  history. 
She  had  always  been  somewhat  delicate,  but  had  never  had  any  especial  disease,  and 
was  considered  to  be  fairly  healthy,  until  she  was  twelve  years  old.  She  then  began 
to  grow  very  fast  in  height  without  a  corresponding  development  in  weight  and  gen- 
eral muscular  strength.  When  she  was  twelve  and  a  half  years  old  the  catamenia 
appeared,  and  were  accompanied  by  severe  pain.  Six  weeks  later,  the  catamenia  again 
appeared,  and  were  accompanied  by  considerable  pain  and  general  prostration.  The 
child  at  this  time  looked  pale  and  thin,  had  very  little  appetite,  and  was  easily  fatigued. 
A  physician  was  consulted,  who  prescribed  strong  food,  such  as  meat,  a  tonic,  and 
gymnasium  exercise.  This  ad'S'ice  was  followed  implicitly,  and  the  child  was  made  to 
exercise  especially  the  muscles  connected  with  the  abdomen  and  pelvis  three  or  four 
times  a  week  at  the  gymnasium,  and  by  daily  home  exercise,  such  as  lying  on  the 
back  and  raising  the  legs.  Under  this  treatment  the  child  rapidly  gre^v  worse,  and  the 
catamenia  did  not  return  in  the  following  month. 

A  physical  examination  of  the  child  showed  nothing  abnormal  beyond  too  rapid 
growth.  The  total  quantity  of  urine  in  twenty-four  hours  was  960  c.c.  (32  ounces). 
The  color  was  normal,  reaction  acid,  speciiic  gravity  1023,  urea  increased,  a  very  slight 
trace  of  albumin,  sugar  absent.  The  sediment  showed  a  considerable  amount  of 
mucus,  a  little  vaginal  epithelium,  an  occasional  granular  and  epithelial  cast,  renal 
epithelium,  and  an  occasional  blood-globule. 

The  urine  was  simply  one  which  showed  a  slight  renal  hypersemia,  and  the  child 
was  therefore  treated  as  follows.  She  was  not  allowed  to  go  to  school  or  to  the  gymna- 
sium, but  was  made  to  rest  in  bed  for  several  hours  twice  a  day.  Her  diet  was  largely 
milk  in  considerable  quantity,  meat  especially  being  withheld.  She  was  also  made  to 
drink  freshly  distilled  water,  250  c.c.  (about  eight  ounces)  once  in  six  hours.  She  was 
allowed  to  take  a  slight  amount  of  exercise  out  of  doors,  but  to  a  very  limited  degree. 

Under  this  course  of  treatment  the  child  began  slowly  to  improve.  She  became 
less  anaemic  ;  her  appetite  increased,  and  was  less  capricious  ;  she  began  to  gain  in 
weight,  to  sleep  well,  and  to  have  more  strength. 

Subsequent  examinations  of  the  urine  showed  a  progressive  improvement  until, 
at  the  end  of  one  year,  the  albumin  had  entirely  disappeared  and  the  urine  became 
normal. 

BL-gSMATUEIA    AND    H^EMOGLOBINURIA. 

Haematuria  is  the  term  applied  to  the  presence  of  red  blood-corpuscles 

in  the  urine.  Haemoglobinuria  is  the  term  used  to  describe  those  cases 
in  which  the  haemoglobin  or  blood-pigment  is  present  in  the  urine  with- 
out the  red  blood-corpuscles  themselves.  Both  conditions  are  to  be  con- 
sidered as  symptoms  of  some  priman-  disease  rather  than  distinct  dis- 
eases in  themselves.  Hsematuria  and  haemoglobinuria  are,  as  a  rule, 
easily  recognized  by  the  color  of  the  urine  if  sufficient  blood  or  blood- 
pigment  is  present  to  color  it.  The  color  is  red  if  it  is  due  to  fresh  blood, 
or  brownish  red  if  due  to  blood-pigment  which  has  been  washed  out  of 
the  corpuscles. 

Etiology. — Haematuria  is  often  the  first  indication  of  an  acute  nephritis 
from  any  cause.  It  may  also  occur  as  a  result  of  scorbutus,  haemophilia, 
pernicious  anaemia,  and  leukaemia.  ^Malignant  disease  of  the  kidney, 
uric  acid  concretions  in  the  kidney  and  bladder,  and  trauma,  are  at  times 
the  direct  cause  of  the  condition. 


854  PEDIATRICS. 

Both  hsematuria  and  hasmoglobinuria,  usually  in  small  amounts,  may 
be  caused  by  poisons,  such  as  carbolic  acid,  cantharides,  and  chlorate  of 
potash,  and  also  by  infectious  diseases,  such  as  scarlet  fever,  typhoid,  and 
malaria. 

Paroxysmal  hcemoglobinuria  is  of  rare  occurrence  in  childhood.  The 
cause  is  obscure.  Some  cases  are  probably  of  lualarial  origin ;  many 
others  seem  to  be  dependent  upon  over-exertion  and  exposure  to  cold, 
such  as  may  come  from  chilled  or  wet  feet,  or  from  a  cold-water  plunge. 

Symptoms. — With  the  onset  of  the  attack  there  may  be  severe  symp- 
toms of  chills,  fever,  rapid  and  small  pulse,  and  prostration.  Again  there 
may  be  hardly  any  subjective  symptoms,  the  color  of  the  urine  alone 
being  noticed.  When  the  htematuria  is  dependent  upon  an  acute  ne- 
phritis, the  symptoms  follow  the  course  of  the  primary  infection. 

Diagnosis. — To  determine  the  source  and  cause  of  the  hemorrhage '  is 
often  cjuite  difficult,  and  at  times  is  impossible.  When  the  blood  comes 
from  the  bladder  it  may  not  be  uniformly  diffused  through  the  urine,  and 
small  clots  are  common.  In  addition  to  this  there  are  symptoms  of 
disturbance  of  the  bladder,  such  as  tenesmus  and  frequent  and  perhaps 
interrupted  micturition.  In  hemorrhage  from  the  kidney  the  blood  is 
diffused  through  the  urine.  The"  color  may  be  red  or  brownish  red.  The 
microscopic  examination  shows  epithelium  and  casts  from  the  kidney, 
many  of  which  contain  red  blood-corpuscles  embedded  in  them,  and  are 
known  as  blood-casts,  and  the  renal  elements  are  stained  yellow  and 
brown  from  long  contact  with  the  blood.  There  are  also  normal  blood- 
corpuscles,  and  others  from  which  the  haemoglobin  has  been  washed  out, 
which  appear  as  pale  rings,  the  biconcavity  being  lost. 

The  diagnosis  of  haematuria  rests  upon  the  detection,  by  microscopic 
examination,  of  the  red  blood-corpuscles,  either  in  a  normal  condition, 
or  decolorized,  in  the  urine.  When  these  are  absent  and  the  color  of 
the  urine  suggests  the  presence  of  blood-pigment,  the  htemin  test  by 
glacial  acetic  acid  will  show  the  characteristic  crystals  if  blood-pigment  is 
present. 

Infectious  hsemoglobinuria  has  been  descrilDed  on  page  300, 

Treatment. — The  treatment  of  haematuria  and  hsemoglobinuria  con- 
sists in  that  of  the  primary  diseases.  The  cause  should  be  determined, 
if  possible,  and  the  indications  for  treatment  followed.  Rest  in  bed  and 
a  milk  diet  until  the  urine  is  normal  should  be  enforced, 

CHYLURIA. 

Chyluria  is  a  rare  disease.  Two  forms  are  usually  spoken  of,  the 
tropical  and  the  non-tropical. 

Etioloc4y. — The  tropical  form  is  caused  by  a  parasite,  the  filaria  san- 
guinis hominis,  a  species  of  round-worm.  This  parasite  is  found  in  the 
blood  during  the  night ;  in  the  daytime  the  blood  is  almost  or  entirely  free 
from  them.     The  parasite  is  found  at  times  in  the  urine.     The  exact  con- 


DISEASES   OF   THE   KIDNEYS.  856 

nection  between  the  parasite  and  the  chyluria  has  not  yet  been  deter- 
mined. In  the  non-tropical  form  the  parasite  has  not  been  found.  Cases 
have  been  reported  in  which  the  parasite  appeared  in  an  individual  residing 
in  the  tropics,  and  disappeared  on  his  returning  to  a  cold  climate,  although 
the  chyluria  continued.  The  chyle  is  supposed  to  get  into  the  urine  after 
it  has  left  the  kidney. 

Symptoms. — The  symptoms  of  this  disease  are  shown  chiefly  in  the 
urine.  The  urine  has  a  milky  appearance,  sometimes  a  sour  odor,  and 
tends  to  decompose  rapidly.  The  reaction  is  slightly  acid,  or  neutral. 
Microscopic  examination  shows  the  fluid  to  be  filled  with  fine  granules  or 
fat  drops  in  suspension.  The  urine  at  times  contains  blood-corpuscles, 
and  albumin  is  always  present.  The  attacks  are  apt  to  be  paroxysmal, 
lasting  for  days  or  weeks,  then  ceasing  and  again  recurring.  A  fatty  diet 
may  or  -may  not  cause  an  increase  in  the  chyluria.  The  individuals 
affected  by  the  disease  may  have  a  healthy  appearance.  Coagula  may  at 
times  be  formed  in  the  bladder  and  give  rise  to  pain  and  difficult  micturition. 
The  lymph-nodes,  especially  in  the  inguinal  region,  are  sometimes  enlarged. 

Prognosis. — The  prognosis  of  chyluria  is  doubtful.  It  is  a  disease 
which  lasts  for  a  long  time,  and  may  cause  anaemia  and  emaciation  from 
the  loss  of  fat  and  albumin. 

Treatment. — There  is  no  drug  known  which  destroys  the  embryos 
in  the  blood.  In  infected  districts  the  drinking-water  should  be  boiled. 
A  diet  containing  little  liquid  and  little  fat  will  cause  the  chyle  to  dis- 
appear from  the  urine,  but  this,  of  course,  does  not  constitute  a  cure. 

The  removal  of  the  adult  w^orms  from  the  enlarged  lymph-nodes  by 
surgical  means  has  been  the  most  successful  treatment. 

GLYCOSURIA. 

Glycosuria  is  a  symptom,  characterized  by  the  transient  appearance  of 
sugar  in  th.e  urine.  It  may  result  from  poisoning  with  such  substances  as 
carbonic  acid  gas,  morphine,  or  mercury,  or  it  may  appear  in  connection 
with  acute  infectious  disease,  such  as  diphtheria,  scarlet  fever,  typhoid 
fever,  or  malaria.  It  is  not  infrequently  dependent  upon  some  disturb- 
ance of  the  nervous  system  resulting  from  a  fracture  of  the  skull,  cerebro- 
spinal meningitis,  or  epileptiform  convulsions.  Glycosuria  may  occur  in 
infants  as  well  as  in  children,  although  usually  not  in  those  who  are 
healthy.  Sugar  may  be  found  in  the  urine  of  healthy  infants  for  the  first 
three  or  four  weeks  of  fife.  When  found  in  the  later  months,  it  is  usually 
associated  with  digestive  disturbances.  It  may  depend  partly  on  the  diet, 
and  in  these  cases  is  called  dietetic  or  alimentary  glycosuria,  and  Koplik 
found  glycosuria  in  five  out  of  ten  infants  who  were  taking  a  food  largely 
composed  of  sugar.  The  amount  of  sugar  excreted  is  usually  small  and 
its  appearance  transient,  by  which  the  condition  may  be  readily  dis- 
tinguished from  the  disease  diabetes  mellitus  if  the  urine  is  examined 
frequently  and  at  different  times  during  the  twenty-four  hours. 


856  PEDIATRICS. 

CLASSIFICATION    OF    DISEASES    OF    THE    KIDNEY. 
A  classification  of  diseases  of  the  kidney  purely  upon  an  etiological 
basis,  or  upon  the  urine  analysis  is  impossible.     It  must  therefore   be 
founded  upon  the  character  of  the  anatomical  lesions.     We  shall  follow 
that  suggested  by  Councilman  : 

(1).    Acute  Degeneration.  (3).    Sub-Acute  Glomerular  Nephritis. 

(2).    Acute  Nephritis.  (4).    Chronic  Nephritis. 

(a)    Glomerular.  (a)    Glomerular. 

(6)     Interstitial.  (b)     Interstitial. 

ACUTE    DEGENERATION. 

Etiology. — An  acute  degeneration  of  the  kidneys  may  arise  in  the 
course  of  various  acute  infectious  diseases  from  the  elimination  of  irritat- 
ing soluble  toxins.  Fermental  diarrhoeas  and  acute  ileo-colitis  are  frequent 
causes  of  acute  irritation  in  children.  It  may  also  be  caused  by  an  excess 
of  uric  acid,  and  by  such  irritating  drugs  as  turpentine,  cantharides,  and 
arsenic,  lead,  large  doses  of  calomel,  salicylic  acid,  and  potassium  chlorate. 
Concentrated  urines,  and  urines  containing  bile  and  sugar,  also  act  as  irri- 
tants, and  lead  to  a  degenerative  condition  of  the  kidneys.  Irritants  due 
to  inflammations  of  the  bladder  from  gonorrhoeal  and  tubercular  infections 
may,  by  extension  upward  along  the  ureters,  give  rise  to  an  acute  degen- 
eration of  the  straight  or  collecting  tubules.  When  the  action  of  these 
causes  is  very  intense,  or  when  the  irritation  is  sufficiently  prolonged,  the 
lesions  and  symptoms  of  the  severer  forms  of  acute  diffuse  nephritis  are 
developed. 

Pathological  Anatomy. — The  pathological  conditions  resulting  from 
acute  degeneration  of  the  kidneys  are  represented  by  degeneration  and 
desquamation  of  the  renal  epithelium  and  injection  of  the  blood-vessels. 
In  many  cases  it  is  not  to  be  distinguished  from  the  lesions  of  acute 
glomerular  nephritis. 

Symptoms. — Unless  the  irritation  is  very  pronounced,  there  are,  as  a 
~rule,  no  general  symptoms. 

Urine. — The  urine  is  clear,  acid,  and  its  color  is  often  normal.  If  the 
irritation  is  due  to  a  febrile  disturbance,  the  urine  is  generally  high- 
colored,  concentrated,  and  diminished.  If  the  cause  is  not  febrile,  the 
urine  is  often  either  normal  in  quantity  or  dilute.  The  amount  is 
diminished.  The  specific  gravity  is  generally  increased.  The  solids  are 
either  normal  or  slightly  diminished.  There  is  a  slight  sediment,  with  a 
slightest  possible  trace  of  albumin.  Microscopic  examination  shows  the 
presence  of  renal  epithelium  and  blood-corpuscles ;  the  latter,  however, 
are  not  in  sufficient  number  to  color  the  urine.  There  are  also  leuco- 
cytes, and  hyaline  and  fine  granular  casts  with  an  occasional  epithelial 
cast  and  blood  cast ;  the  last  three  varieties  of  casts,  however,  are  not 
very  numerous. 


DISEASES   OF   THE   KIDNEYS.  857 

In  the  severer  forms  of  irritation  the  albumin  may  be  present  in  large 
traces.  It  is  doubtful,  however,  whether  it  is  important  or  possible  to 
attempt  to  distinguish  from  the  clinical  signs  and  symptoms  an  acute  de- 
generation of  the  kidney  from  a  mild  acute  glomerular  nephritis.  But  if 
the  class  of  cases  above  described  are  to  be  classified  as  a  form  of  acute 
nephritis,  it  is  of  the  utmost  importance  to  recognize  that  the  diagnosis 
of  acute  degenerative  nephritis  does  not  carry  with  it  the  serious  prognosis 
that  is  usually  associated  with  the  term  acute  nephritis  or  acute  diffuse 
nephritis. 

Prognosis. — The  prognosis  in  these  milder  forms  of  irritation  is  good. 
Dropsy  never  develops,  the  blood  and  renal  elements  rapidly  disappear 
from  the  urine  upon  removal  of  the  cause,  and  the  urine  soon  regains  its 
normal  condition. 

Treatment. — The  child  should  be  placed  on  a  diet  exclusively  of  milk, 
so  as  to  avoid  any  further  irritation  of  tlie  kidneys,  and  should  be  made 
to  drink  a  great  deal  of  water.  It  should  be  kept  quiet,  and  its  general 
hygiene  carefully  regulated.  Sweet  spirit  of  nitre,  potassium  citrate, 
and  cream  of  tartar  water  may  advantageously  be  given  to  increase  the 
flow  of  urine. 

The  cause  of  tlie  irritation  should  be  diligently  sought  for,  and  when 
found  should  be  appropriately  treated. 

PASSIVE  CONQESTION. 

In  addition  to  the  acute  degeneration  of  the  kidney  which  has  just  been 
described,  chronic  passive  congestion  may  occur,  dependent  upon  dimin- 
ished arterial  or  increased  venous  pressure.  This  condition  occurs  in 
chronic  cardiac  disease  with  disturbance  of  compensation,  in  chronic  pul- 
monary disease,  and  when  there  is  mechanical  obstruction  to  the  venous 
circulation,  as  from  the  presence  of  abdominal  tumors  or  ascitic  fluid. 

Pathological  Anatomy. — The  kidney  is  enlarged,  firm,  and  of  a  deep- 
red  color.  The  substance  is  tough  from  increase  of  interstitial  tissue.  The 
vessels  are  congested  and  their  walls  become  thickened  in  long-continued 
cases.  The  epithelium  of  the  tubules  shows  granular  or  fatty  degenera- 
tion. 

Symptoms. — The  symptoms  which  occur  in  the  course  of  passive  con- 
gestion are  only  slightly  referable  to  the  kidney,  and  depend  for  the  most 
part  upon  the  disease  which  causes  the  condition. 

Urine. — The  urine  in  this  condition  is  high-colored,  strongly  acid,  and 
often  considerably  diminished  in  amount.  It  usually  has  a  high  specific 
gravity,  and  often  a  heavy  sediment  of  amorphous  urates.  The  total  solids 
are  diminished  absolutely,  but  owing  to  the  concentration  of  the  urine  are 
relatively  increased.  There  is  a  slight  trace  of  albumin,  usually  under 
one-tenth  of  one  percent.  Microscopic  examination  shows  a  few  hyaline 
casts  with  renal  cells  adherent  and  an  occasional  blood-corpuscle.  There 
are,  however,  very  few  of  these  elements  in  the  sediment.     If  the  urine 


858  PEDIATRICS. 

is  passed  in  larger  quantities,  it  is  not  so  highly  colored  and  contains  a 
smaller  amount  of  albumin. 

Diagnosis. — The  diagnosis  of  passive  congestion  from  acute  degenera- 
tion usually  cannot  be  made  from  the  urine  alone,  owing  to  the  association 
of  the  two  conditions.  The  amount  of  blood  elements  in  the  urine  is 
the  principal  test.  The  main  reliance  must  be  placed  upon  the  clinical 
history  and  physical  examination. 

Prognosis. — The  prognosis  in  cases  of  passive  congestion  of  the 
kidney  depends  upon  the  cause  of  the  condition. 

Treatment. — The  treatment  is  to  be  directed  to  the  cause  or  causes  of 
the  congestion. 

ACUTE  GLOMERULAR  NEPHRITIS. 

This  condition  is  also  described  under  the  name  Acute  Brighfs  Disease, 
Acute  Diffuse  Nephritis,  and  also  Acute  Nephritis. 

Etiology. — The  most  common  cause  of  acute  diffuse  nephritis  in  chil- 
dren is  scarlet  fever.  Other  diseases  in  the  course  of  which  it  may  arise 
are  diphtheria,  measles,  varicella,  erysipelas,  typhoid  fever,  malaria,  small- 
pox, meningitis,  septicaemia,  pertussis,  and  pneumonia.  With  the  excep- 
tion of  its  occurrence  in  scarlet  fever,  diphtheria,  measles,  and  pneumonia, 
the  disease  is  not  frequent.  Cases  have  been  reported  in  which  it  has 
arisen  in  the  course  of  extensive  affections  of  the  skin,  such  as  eczema. 
Cases  of  primary  nephritis  have  been  reported  in  which  no  cause  could  be 
found.  Although  it  is  difficult  to  estimate  with  certainty  the  importance 
of  cold  as  a  causative  factor  in  the  etiology  of  acute  nephritis,  and  although 
it  has  been  denied  that  cold  can  produce  this  condition,  yet  numerous 
cases  have  followed  exposure  to  wet  and  cold. 

In  most  of  the  diseases  due  to  infectious  fevers  the  lesions  in  the 
kidney  are  dependent  chiefly  upon  the  action  of  the  toxins.  Some- 
times direct  bacterial  infection  is  a  cause,  and  the  course  of  the  disease  is 
-especially  severe  in  such  cases.  Any  of  the  causes  of  acute  degeneration 
described  on  page  856,  may  be  a  cause  of  an  acute  diffuse  nephritis  if 
sufficiently  severe. 

Pathological  Anatomy. — According  to  Councilman,  acute  diffuse  ne- 
phritis includes  a  number  of  different  pathological  conditions,  described  as 
(a)  acute  degeneration  ;  (b)  acute  glomerular  nephritis  ;  (c)  acute  hemorrhagic 
nej)hritis  ;  and  (d)  acute  interstitial  nephritis.  These  forms  have  been 
decribed  in  some  detail  under  scarlet  fever,  on  page  544. 

From  a  clinical  point  of  view,  these  various  forms  cannot  always  be 
differentiated  by  the  character  of  the  urine  even  when  studied  in  connec- 
tion W'ith  the  history  and  symptoms. 

Symptoms. — The  symptoms  of  acute  nephritis  are  such  as  have  been 
already  described  under  scarlet  fever  on  page  568.  In  general,  the  symp- 
toms arising  in  cases  due  to  other  causes  than  scarlet  fever  are  the  same, 
but  less  severe  than  those  described  in  connection  with  that  disease. 
Briefly  they  may  be  stated  to  be,  sudden  onset  with  mild  fever ;  rapid 


DISEASES   OF   THE   KIDNEYS.  859 

development  of  anaemia ;  swelling  of  the  eyelids,  face,  ankles,  and  often 
general  anasarca ;  headache,  thirst,  nausea,  and  vomiting ;  frequent  mic- 
turition, but  diminished  quantity  ;  and  in  case  of  the  advent  of  ursemia, 
stupor  and  convulsions. 

Urine. — The  characteristics  of  the  urine  are  generally  described  ac- 
cording to  three  stages.  Whereas,  these  stages  may  often  be  observed  in 
typical  cases  of  acute  nephritis,  there  may  be  great  discrepancies  between 
the  urinary  analysis  and  the  pathological  conditions  as  shown  at  autopsy. 
Severe  cases  of  nephritis  may  occur  with  very  slight  changes  in  the  urine, 
so  that  the  nature  of  the  renal  lesions  may  be  overlooked  if  too  much  re- 
liance is  placed  upon  the  results  of  the  examination  of  the  urine. 

First  or  Acute  Stage. — The  quantity  is  very  much  diminished,  at  times 
almost  suppressed.  The  color  is  dark,  smoky,  or  blood-red.  The  re- 
action is  acid,  rarely  alkaline  from  the  presence  of  blood.  The  specific 
gravity  is  low  or  high ;  it  may  be  high  from  the  presence  of  albumin. 
The  normal  solids  are  diminished  both  absolutely  and  relatively,  especially 
the  chlorine  and  urea.  The  albumin  varies  from  one-fourth  to  one-half 
of  one  per  cent.  The  sediment  is  abundant  and  is  of  a  dark-brown  color. 
There  are  large  numbers  of  normal  and  decolorized  blood-corpuscles  and 
brown  granular  renal  cells.  Brown  granular,  epithelial,  blood,  fibrinous, 
and  even  hyaline  and  finely  granular  casts  are  seen  in  abundance.  There 
may  also  be  evidence  of  an  acute  pyelitis^  as  shown  by  clumps  of  caudate 
cells,  round  cells,  and  leucocytes.     This  stage  lasts  from  five  to  ten  days. 

Second  or  Fatty  Stage. — In  this  stage  the  quantity  of  urine  and  solids 
excreted  begins  to  increase,  the  albumin  to  diminish,  and  the  sediment  to 
become  more  dilute,  with  the  same  characteristics,  but  with  the  addition 
of  fatty  tenal  cells,  fatty  casts,  and  compound  granule-cells.  This  stage 
lasts  about  as  long  as  the  first  stage. 

Third  Stage.,  or  Stage  of  Convalescenec. —  In  this  stage  there  is  a 
marked  increase  in  the  quantity  of  urine,  which  gradually  loses  its 
dark  and  smoky  color  and  becomes  pale,  faintly  acid,  of  low  specific 
gravity,  and  with  only  a  trace  of  albumin.  The  solids  are  nearly  normal 
in  absolute  amount,  but  relatively  are  diminished,  owing  to  the  increased 
amount  of  urine.  The  sediment  becomes  slight  in  quantity,  colorless,  and 
shows  a  great  diminution  in  the  number  of  renal  elements  seen  in  the 
fatty  stage.  This  stage  may  last  from  several  months  to  several  years, 
and  be  followed  by  complete  recovery,  especially  in  children. 

Exacerbations  may  occur  at  any  time  in  the  course  of  the  second  and 
third  stages,  and  be  followed  by  the  return  of  the  characteristics  of  the 
first  stage.  There  is  a  sudden  drop  in  the  quantity  of  urine,  with  the  re- 
appearance or  increase  of  the  blood  elements,  especially  of  fresh  red  blood- 
corpuscles,  the  amount  depending  upon  the  intensity  of  the  exacerbations. 

Complications. — Pneumonia,  pleurisy,  endocarditis,  and  pericarditis 
should  all  be  carefully  watched  for,  as  they  may  occur  any  time  in  the  course 
of  an  acute  nephritis.     Uraemia,  however,  is  the  condition  especially  to  be 


860 


PEDIATRICS. 


guarded  against.  With  a  fall  in  the  amount  of  urine  and  diminution  in 
the  amount  of  solids,  as  judged  by  a  daily  examination  of  the  urea, 
special  measures  should  be  taken  to  increase  the  elimination  of  the  toxic 
substances  by  diuresis,  diaphoresis,  or  free  catharsis. 

Differential  Diagnosis. — The  distinction  between  a  severe  acute  de- 
generation and  acute  glomerular  nephritis  is  often  impossible.  The  pres- 
ence of  oedema  and  the  persistence  of  albumin,  blood,  and  casts  in 
consideraJDle  amounts  point  strongly  to  an  acute  nephritis.  On  the  other 
hand,  acute  nephritis  may  exist  with  no  oedema  and  with  the  urine 
such  as  is  described  under  acute  degeneration.  In  the  convalescent  stage  of 
an  acute  nephritis  in  which  there  is  a  large  amount  of  urine  and  a  small  per- 


FiG.   182. 


Acute  glomerular  nephritis,  following  scarlet  fever. 


centage  of  albumin,  the  characteristics  of  the  urine  resemble  those  which 
occur  in  a  chronic  interstitial  nephritis,  but  the  history  of  an  acute  attack, 
the  normal  solids  and  presence  of  blood,  and  the  rarity  of  chronic 
nephritis  in  children  enable  us  to  make  the  diagnosis. 

Cardiac  disease  with  dropsy  is  to  be  distinguished  either  from  acute 
glomerular  nephritis  or  subacute  glomerular  nephritis  by  the  evidences  of 
valvular  lesions  and  the  character  of  the  urine  in  cardiac  disease,  which 
is  that  of  a  passive  congestion. 

Fig.  182  illustrates  the  character  of  the  dropsy  which  may  occur  in 
the  course  of  an  acute  nephritis.     The  case  is  described  on  page  573. 

Treatment. — The  treatment  of  acute  nephritis  consists  primarily  in 
the  administration  of  a  strict  milk  diet,  rest  in  bed,  and  the  free  use  of 
diuretics.  The  details  of  the  treatment  and  of  the  complications  which 
may  arise,  such  as  uraemia,  have  been  sufficiently  described  in  connection 
with  nephritis  following  scarlet  fever  on  page  568. 


DISEASES    OF    THE    KIDXEYS.  881 

ACUTE  INTERSTITIAL  NEPHRITIS. 

Acute  interstitial  nepliritis  is  not  uncommon  in  children.  It  occurs 
chiefly  in  active  infectious  diseases,  especially  diphtheria.  It  has  no  con- 
nection with  chronic  interstitial  nephritis. 

Pathological  Anatomy. — The  kidney  is  large,  pale  and  somewhat 
mottled.  The  essential  lesions  consist  in  a  proliferation  of  lymphoid  cells 
from  the  vascular  endothelium  into  the  inter-lobular  tissue.  The  cells  are 
found  chiefly  in  foci  beneath  the  capsules  and  around  the  glomeruli.  The 
glomeruli  themselves  are  not  affected,  but  the  tubules  show  degeneration 
and  necrosis. 

Symptoms. — This  form  of  nephritis  cannot  be  differentiated  chemically 
from  acute  degeneration.  There  is  no  oedema  and  the  urine  may  show 
only  slight  diminution  in  quantity  and  small  amounts  of  albumin,  casts, 
epithelial  cells  and  leucocytes.  Severe  pathological  lesions  may  exist  in 
the  kidney  without  corresponding  chemical  signs. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  is  the  same  as 
in  acute  glomerular  nephritis. 

SUBACUTE  GLOMERULAR  NEPHRITIS. 

This  condition  is  known  also  as  "  chronic  parenchymatous  nephritis.'''' 

Etiology. — Subacute  glomerular  nephritis  is  not  a  common  disease 
in  childhood,  and  its  etiology  is  still  very  obscure.  Some  cases  .have 
followed  an  attack  of  acute  nephritis,  and  in  these  there  has  generally 
been  an  interval  during  which  the  urine  has  contained  simply  a  trace  of 
albumin  and  a  few  casts,  the  symptoms  of  a  chronic  affection  of  the 
kidney  appearing  later.  Cases  have  also  occurred  in  connection  with 
long- continued  suppurative  processes  in  the  bones,  joints,  or  elsewhere, 
arising  in  the  course  of  tuberculosis  or  syphilis.  In  these  cases  amyloid 
infiltration  is  also  apt  to  occLir.  1q  the  majority  of  instances  no  cause 
whatever  can  be  discovered. 

Pathological  Anatomy. — The  kidney  is  enlarged,  pale,  slightly  mottled, 
and  of  increased  consistency.  The  cortex  is  increased  in  width  and  is 
pale.  The  markings  are  indistinct.  The  essential  lesions  consist  of  swell- 
ing and  increase  in  the  nuclear  elements  of  the  glomeruli,  ^vith  hyaline  de- 
generation of  the  blood-vessels.  There  is  proliferation  and  desquamation 
of  the  capsular  epithelium  and  new  formation  of  connective  tissue.  Diffuse 
degeneration  and  desquamation  of  the  tubular  epithehum  and  oedema  of 
the  inter-tubular  tissue  occur. 

Symptoms. — The  onset  of  subacute  glomerular  nephritis,  or  chronic 
parenchymatous  nephritis,  is  sometimes  insidious.  Indigestion,  loss  of 
appetite,  and  vomiting  are  early  symptoms.  The  face  becomes  pallid  and 
"pasty,"  and  oedema  of  the  face,  eyes,  and  ankles  develops.  Palpita- 
tion, headache,  and  dyspnoea,  with  hypertrophy  of  the  heart  and  pulse  of 
increased  tension,  are  present  and  are  often  early  symptoms.  Epistaxis 
may  occur.     Nervous  symptoms  of  an  ursemic  type  are  often  pronounced, 


862  PEDIATRICS. 

and  in  the  more  advanced  stages  of  the  disease  may  end  in  convulsions 
and  coma.  Changes  in  the  retina  are  often  found,  and  there  is  always  a 
special  tendency  towards  the  development  of  intercurrent  diseases,  such 
as  pneumonia  and  pleurisy,  which  often  lead  to  a  fatal  conclusion.  As 
the  disease  advances  the  oedema  becomes  more  general,  and  a  condition 
of  anasarca  develops.  The  anaemia  becomes  more  profound  and  the 
cardiac  symptoms  more  marked.  Clinically  we  may  distinguish  active 
and  inactive  stages. 

Urine. — Micturition  is  frequent,  but  the  quantity  of  urine  which  is 
passed  is  small.  The  disease  is  characterized  by  periods  of  activity  and 
quiescence.  In  the  active  stages  the  oedema  is  increased,  the  quantity 
of  urine  is  very  small,  and  ureemic  symptoms  threaten.  The  urine  is 
high-colored,  strongly  acid,  Avith  high  specific  gravity,  and  the  solids  are 
absolutely  much  diminished,  although  relatively  they  may  be  increased. 
The  albumin  is  usually  very  large,  averaging  from  one-half  to  one  per 
cent.,  although  it  is  sometimes  much  higher.  The  sediment  consists  of 
many  hyaline,  granular,  and  fatty  casts,  some  of  which  contain  fatty  renal 
cells  and  compound  granule-cells  adherent.  These  fatty  degenerated 
cells  are  also  found  free.  In  advanced  stages  waxy  casts  will  be  met 
with  and  are  usually  of  bad  prognosis.  Signs  of  acute  irritation  of  the 
kidney  are  often  present  and  are  indicated  by  the  presence  of  blood 
elements. 

During  tlie  quiescent  stage  the  dropsy  becomes  absorbed,  and  the 
oedema  may  entirely  disappear.  This  change  is  associated  with  a  marked 
increase  in  the  quantity  of  urine,  which  may  become  normal  or  even  in 
excess  of  the  normal  limit.  As  a  result,' the  urine  becomes  pale,  of  a  lower 
specific  gravity,  and  with  solids  which  are  both  relatively  and  absolutely 
diminished.  The  albumin  remains  high,  ranging  from  one-fourth  to  one- 
half  per  cent.  The  sediment  is  the  same  as  in  the  active  stage,  but  the 
renal  elements  are  less  numerous. 

Diagnosis. — It  is  important  not  to  overlook  a  subacute  glomerular 
nephritis  when  complicated  with  an  acute  nephritis,  for  the  prognosis  is 
very  different  in  the  two  conditions.  The  diagnosis  can  only  be  made  by 
attention  to  the  history  of  the  case  and  to  the  changes  which  take  place  in 
the  urine.  If  the  case  is  one  of  a  subacute  glomerular  nephritis  compli- 
cated with  an  acute  process,  the  disappearance  of  the  blood  elements  in 
favorable  cases  is  not  associated  with  material  reductions  in  the  amount 
of  albumin  or  of  the  fatty  elements.  The  quantity  of  urine  and  total 
solids  do  not  return  to  normal,  and  the  anaemia  and  tendency  t'O  oedema 
increases. 

Prognosis. — The  prognosis  is  very  grave.  A  few  very  rare  cases  of 
recovery  have  been  reported.  Most  cases,  however,  die  from  uraemic  in- 
toxication or  from  some  intercurrent  disease,  such  as  pneumonia.  There 
may  be  a  remission  in  the  symptoms  for  a  time.  The  duration  of  the 
disease  is  from  one  to  five  vears. 


DISEASES   OF   THE    KIDNEYS.  863 

Treatment. — The  treatment  of  subacute  glomerular  nephritis  is  essen- 
tially the  same  as  in  acute  glomerular  nephritis.  The  diet  should  be 
restricted  as  far  as  possible  to  milk.  Good  hygienic  surroundings  and  as 
much  rest  as  possible  are  indicated. 

The  use  of  diuretics  and  the  treatment  of  general  oedema  and  threat- 
ened uraemia  have  been  described  in  detail  in  the  chapter  on  scarlet  fever 
(page  569).  The  ansemia  is  to  be  treated  with  iron,  especially  the  tincture 
of  the  chloride,  but  the  indications  for  iron  should  be  determined  -by  the 
blood  examination  and  not  from  the  pallor.  Exposure  to  cold  must  be 
avoided,  and  residence  in  a  warm,  even  climate  during  the  winter  months 
is  very  desirable.  The  skin  must  be  kept  active  by  bathing  and  friction, 
and  moderate,  regular  exercise  taken  when  the  child  is  strong  enough. 
Cardiac  dilation  is  to  be  combated  with  digitalis  and  strychnine. 

CHRONIC    GLOMERULAR    NEPHRITIS. 

Chronic  glomerular  nephritis  is  considered  as  the  end  stage  of  acute  or 
subacute  glomerular  nephritis.  It  gives  rise  to  the  so-called  secondary 
contracted  kidney.  The  lesions  consist  of  hyaline  degeneration  of  the 
tufts  and  obliteration  of  the  capillaries  of  the  glomeruli  in  places,  while  in 
others  the  same  changes  are  seen  as  in  acute  and  subacute  glomerular 
nephritis.  The  connective  tissue  is  increased  and  diffusely  distributed 
throughout  the  kidney. 

Symptoms. — There  is  usually  oedema,  which,  slight  at  first,  increases  as 
the  disease  advances.  (Edema  may  be  absent  even  in  cases  with  well 
advanced  pathological  lesions.  The  face  is  pale,  malnutrition  is  pro- 
nounced and  digestive  and  circulatory  disturbances  are  generally  present. 

Urine. — The  urine  is  normal  or  increased  in  amount,  pale  in  color  and 
with  a  specific  gravity  which  is  variable  owing  to  the  fact  that  the  daily 
quantity  may  in  different  cases  be  high  or  low  in  amount.  The  albumin 
is  present  in  much  smaller  amounts  than  in  the  subacute  glomerular  form, 
the  sediment  is  less  and  the  fatty  and  renal  elements  are  not  so  numerous. 
Blood  is  present  only  in  complicated  cases.  The  condition  can  be  dis- 
tinguished from  chronic  interstitial  nephritis  only  by  the  knowledge  of  the 
history  of  the  cases,  most  of  them  giving  evidence  of  a  previous  attack  of 
subacute  glomerular  nephritis,  by  the  larger  amounts  of  fatty  elements  and 
albumin  than  is  usually  present  in  interstitial  nephritis  and  by  the  greater 
tendency  to  oedema. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  do  not  differ 
from  those  of  chronic  interstitial  nephritis.  Edebohl's  operative  treatment 
has  not  met  with  marked  success  in  children  in  the  small  number  of  cases 
in  which  it  has  been  tried. 

CHRONIC   INTERSTITIAL  NEPHRITIS. 
Chronic  interstitial  nephritis  is  scarcely  ever  seen  in  infants  and  rarely 
occurs  in  children  under  five  years  of  age. 


864  PEDIATRICS. 

Etiology. — The  etiology  of  chronic  interstitial  nephritis  is  obscure. 
Hereditary  tendencies  and  congenital  syphilis  play  a  part  in  the  produc- 
tion of  the  disease  in  young  children,  but  the  common  predisposing  or 
associated  conditions  which  are  found  in  adults,  such  as  gout,  lead  poi- 
soning, chronic  alcoholism,  and  arterio-sclerosis  are  very  rare  in  childhood. 
In  some  cases  a  subacute  glomerular  nephritis  is  followed  by  a  chronic 
interstitial  nephritis. 

Pathological  Anatomy. — The  pathological  conditions  do  not  differ  from 
the  lesions  as  seen  in  the  adult.  The  kidneys  are  very  small  and  con- 
tracted with  thick  adherent  capsules.  The  color  is  reddish,  and  on  section 
the  cortex  is  seen  to  be  thin,  the  pyramids  wasted,  and  the  arteries  thick- 
ened. The  glomeruli  are  injected,  and  the  pyramids  show  passive  con- 
gestion. On  microscopic  examination  the  connective  tissue  between  the 
tubules  is  much  increased.  The  epithelium  is  degenerated.  A  general 
condition  of  arterio-sclerosis  prevails.  The  kidney  is  that  known  as  the 
primary  contracted  kidney. 

Symptoms. — The  diagnosis  can  scarcely  be  made  from  the  symptoms. 
The  disease  is  progressive  and  slow,  with  no  characteristic  symptoms. 
Cases  have  been  reported  in  which  there  were  headache,  weakness, 
dyspnoea,  palpitation,  and  disturbance  of  vision.  Hypertrophy  of  the 
left  ventricle,  with  a  pulse  of  increased  tension,  occurs  as  a  constant 
lesion.  There  is  little  tendency  to  (Bdema ;  retinitis  may  be  present. 
Sometmies  severe  nen^ous  symptoms  are  prominent,  such  as  tremor, 
increased  reflexes,  aphasia,  and  psychoses.  Cerebral  hemorrhages  may 
occur  as  in  adults.  Baginsky  refers  to  the  lack  of  development  of  the 
children  in  these  cases,  and  this  condition  was  noticed  in  a  case  of  this 
disease  wliich  occurred  at  the  Boston  Children's  Hospital. 

This  child,  a  girl,  twelve  years  old,  showed  the  development  of  a  child  of  about 
seven  years.  The  only  symptom  until  she  died  of  ursemic  poisoning  was  persistent 
headache.  The  post-mortem  examination  showed  marked  interstitial  nephritis,  but  it 
was  not  possible  to  determine  whether  it  was  primary  or  not,  and  no  previous  history 
could  be  obtained. 

Urine. — In  chronic  interstitial  nephritis  the  amount  of  urine  passed 
in  the  twenty-four  hours  is  very  greatly  increased.  It  has  a  Ioav  specific 
gravity,  a  ver^^  slight  sediment,  and  a  trace  of  albumin.  The  microscopic 
examination  shows  a  few  hyaline  and  finely  granular  casts  and  occasional 
renal  cells.  Sometimes  towards  the  end  of  the  disease  highly  refractive 
homogeneous  casts  resembling  wax  appear  in  the  urine.  At  this  time  the 
amount  of  urine  may  be  somewhat  diminished,  but  the  specific  gravity 
does  not  rise,  as  the  excretion  of  urea  is  interfered  with. 

Diagnosis. — The  early  stages  are  not  recognizable.  The  cases  demand 
careful  obsen^ation  for  a  long  time  and  repeated  examinations  of  the  urine. 
The  presence  of  cardio-vascular  changes,  such  as  cardiac  enlargement 
and  a  pulse  of  high  tension,  are  important. 


DISEASES    OF   THE    KIDNEYS.  865 

Prognosis. — The  prognosis  is  very  unfavorable.  The  children  usually 
die  of  cerebral  hemorrhage  or  of  some  intercurrent  disease.  It  is  impossible 
to  predict  the  duration  of  the  disease  from  the  symptoms  or  from  the 
urinary  examination.  The  presence  of  marked  cardio-vascular  changes, 
of  cedema  from  failmg  compensation  of  the  hypertrophied  heart,  and  the 
continued  excretion  of  very  small  amounts  of  solids,  especially  of  urea 
are  unfavorable  signs. 

Treatment. — The  treatment  of  chronic  interstitial  nephritis  is  essentially 
the  same  as  that  of  subacute  glomerular  nephritis.  The  diet,  however 
need  not  be  so  strictly  limited.  It  should  be  light  and  nutritious  and 
moderate  in  amount.  Meat  may  be  given  in  small  quantities.  Alcohol 
should  be  prohibited.  Free  use  of  the  mineral  waters  is  beneficial.  In 
general,  the  indications  are  to  maintain  the  functional  activity  of  the  heart 
kidneys,  skin,  and  bowels  according  to  the  methods  which  have  been  de- 
scribed. 

When  the  arterial  tension  is  high,  nitroglycerin  may  be  tried.  As 
evidences  of  failing  compensation  of  the  heart  develop,  appropriate  sup- 
portive treatment  with  strychnine  and  digitalis  should  be  given.  Threat- 
ened uraemia  is  to  be  met. by  the  same  measures  which  have  been  de- 
scribed in  connection  with  acute  nephritis  (page  569). 

AMYLOID  INFILTRATION. 

Amyloid  infiltration  of  the  kidney  may  occur  in  the  kidney  in  connec- 
tion with  amyloid  changes  in  other  organs,  especially  in  the  liver,  spleen, 
and  intestines.  It  is  always  combined  with  other  changes  in  the  kidney, 
usually  those  of  a  chronic  parenchymatous  nephritis,  and  it  is  not  to  be 
considered  as  a  separate  disease  of  the  kidney. 

Etiology. — It  occurs  at  times  in  connection  with  chronic  suppurative 
processes  in  the  bones  or  elsewhere,  and  also  in  tuberculosis,  syphilis,  and 
chronic  wasting  diseases.  It  is  not,  however,  especially  common  in  early 
life. 

Pathological  Anatomy. — The  amyloid  change  usually  begins  in  the 
vessels  of  the  glomeruli  of  the  kidney,  extends  to  other  small  vessels,  and 
finally  to  the  walls  and  epithelium  of  the  tubules.  The  kidneys  always 
show  signs  of  diffuse  nephritis. 

Symptoms. — The  symptoms  are  those  of  chronic  nephritis.  The  char- 
acter of  the  urine,  the  presence  of  a  cause,  and  of  amyloid  changes  in  the 
liver  and  spleen,  shown  clinically  by  enlargement,  are  the  signs  by  which 
the  diagnosis  is  made.  Hypertrophy  of  the  heart  is  rare.  The  urine  is 
usually  passed  in  large  quantity  when  the  amyloid  changes  are.  advanced. 
The  specific  gravity  is  low,  and  albumin  is  present  to  the  extent  of  from 
one-tenth  of  one  per  cent,  to  one  per  cent.  When  the  amount  of  urine  is 
not  much  increased,  as  may  happen  temporarily,  the  albumin  occurs  in 
large  amount.  Microscopic  examination  shows  no  characteristic  sedi- 
ment ;   but  when,  as  may  often  happen,  the   disease  is  combined  with 

55 


866 


PEDIATRICS. 


chronic  nephritis,  the  sediment  will  show  evidence  of  this  latter  disease. 
Waxy  casts  appear  much  earlier  than  in  other  forms  of  chronic  nephritis. 
There  are  no  fatty  elements  unless  the  disease  is  complicated. 

Prognosis. — On  account  of  the  usual  causes  of  this  condition  the  prog- 
nosis is  unfavorable. 

Treatment. — The  treatment  is  the  same  as  that  of  chronic  interstitial 
nephritis  and  of  the  primary  disease  upon  which  the  amyloid  changes  are 
dependent. 

The  case  which  follows  illustrates  a  subacute  glomerular  nephritis 
with  an  acute  exacerbation : 

The  boy  was  eleven  years  old,  and  had  had  nephritis  for  one  year.  He  had 
pertussis  when  he  was  three  years  old,  scarlet  fever  when  he  was  four  years  old, 
and  measles  and  pneumonia  when  he  was  five  years  old.  He  is  reported  to  have 
remained  well  from  that  time  until  nine  months  before  he  came  under  my  observa- 

FiG.  183. 


Probable  subacute  glomerular  nephritis  with  an  acute  exacerbation.    Male,  11  years  old.    Relapse  after 

being  out  of  bed  five  days. 


tion,  when,  without  any  known  cause,  such  as  exposure  to  cold  or  sickness  of  any 
kind,  his  face  and  eyes  began  to  be  osdematous.  This  was  followed  by  oedema  of  the 
legs  and  ankles,  and  was  accompanied  by  dyspnoea.  The  urine  was  noticed  to  be 
nearly  of  the  color  of  blood,  and  to  be  lessened  in  amount.  He  was  kept  in  bed  for 
six  weeks,  and  is  said  not  to  have  complained  of  any  especial  discomfort.  During  this 
attack  his  appetite  remained  fair.  From  the  beginning  of  the  attack  he  grew  weak  and 
pale.  Six  weeks  before  the  present  history  the  paleness  and  oedema  about  the  eyes  in- 
creased, and  the  urine  became  smoky  again.  This  was  followed  by  oedema  of  the 
ankles,  feet,  and  legs,  accompanied  by  dyspnoea.  The  bowels  were  regular,  and  there 
was  no  vomiting.  Sleep  was  not  disturbed.  On  entering  the  hospital  his  face  looked 
pale  and  waxy.  There  was  considerable  cedema  of  the  face,  especially  of  the  eyes. 
His  tongue  was  slightly  coated,  and  there  was  osdema  of  the  ankles,  feet,  and  legs. 
Nothing  abnormal  was  found  in  the  heart  or  lungs,  and  there  was  no  evidence  o| 
ascites. 


DISEASES    OF    THE    KIDNEYS.  867 

He  was  kept  in  bed  and  given  a  diet  of  milk.  Under  this  treatment  the  cedema 
and  anaemia  disappeared  rapidly,  and  in  two  weeks  he  was  allowed  to  be  dressed  and 
about  the  ward.  Five  days  later  he  again  had  oedema  of  the  face,  and  was  immediately 
put  to  bed.  From  750  to  900  c.c.  (25  to  30  ounces)  of  urine  were  passed  in  the 
twenty-four  hours.  An  examination  showed  it  to  have  a  specific  gravity  of  1010,  an 
acid  reaction,  to  contain  about  9  grammes  (140  grains)  of  urea  in  the  twenty-four- 
hour  quantity,  to  have  the  chlorides  diminished,  and  to  contain  0.6  of  one  per  cent. 
of  albumin,  but  no  sugar.  The  sediment  showed  numerous  hyaline  casts  of  medium 
diameter,  some  of  large  diameter  from  the  straight  tubules,  many  coarse  and  fine 
granular  casts,  numerous  fibrinous  casts,  and  many  casts  with  renal  cells  adherent ; 
also  epithelial  casts  and  blood  casts ;  an  excess  of  renal  epithelium,  most  of  it  granular 
or  fatty  ;  a  large  amount  of  abnormal  blood,  free  fat,  and  fatty  casts.  His  temperature 
varied  from  36.6°  to  37.2°  C.  (98°  to  99°  F.). 

After  remaining  in  the  hospital  for  two  months,  with  temporary-  periods  of  im- 
provement, he  was  discharged  in  about  the  same  condition  as  when  he  entered. 

The  following  represents  another  case  of  the  same  type: 

Fig.   1S4. 


Probable  subacute   glomerular  nephritis  ^vith  an  acute  exacerbation.    Female,   9  yeare  old.    Second 

week  of  the  disease. 

This  child  had  measles  when  she  was  two  years  old,  scarlet  fever  when  she  was 
three  years  old,  varicella  when  she  was  six  years  old,  and  pertussis  when  she  was  eight 
years  "old.  She  apparently  recovered  entirely  from  all  these  diseases,  and  was  well 
until  one  week  before  entering  the  hospital,  when,  without  any  apparent  cause,  her 
face  and  feet  began  to  swell.  She  complained  of  no  pain,  and  had  no  other  symptoms. 
There  was  marked  and  extensive  oedema  of  the  entire  face,  body,  and  limbs.  There 
was  also  a  pronounced  pallor  of  the  skin.  Nothing  abnormal  was  detected  in  the  heart 
or  lungs.     There  were  no  ascites,  headache,  nor  discomfort. 

An  examination  of  the  urine  showed  the  color  to  be  pale,  the  reaction  acid,  the 
specific  gravity  1012,  and  the  sediment  moderate  ;  it  contained  0.25—  of  one  per  oent. 
albumin"!  and  no  sugar  ;  the  sediment  contained  considerable  abnormal  blood,  some  free 
fat,  and  a  number  of  hyaline  and  fine  granular  casts  of  medium  and  small  diameter, 
many  of  them  short  and  with  fat-globules  adherent.     There  was  some  fatty  renal  epi- 


868  PEDIATRICS. 

thelium,  leucocytes,  casts  with  renal  epithelium,  and  hyaline  casts  with  a  few  renal  cells 
adherent.     There  were  also  several  fatty  casts.     The  casts  were  not  very  numerous. 

She  was  treated  by  absolute  rest  in  bed.  bitartrate  of  potassium,  digitalis,  and  a 
diet  of  milk.  In  about  a  week  the  oedema  rapidly  diminished  and  the  urine  increased 
in  amount.  An  analysis  of  the  urine  at  this  time  showed  that  the  color  was  pale,  that 
it  had  a  speciiic  gravity  of  1010,  a  trace  of  alljumin,  and  a  slight  sediment,  consisting 
of  a  small  amount  of  blood,  renal  epithelium,  and  a  few  casts  with  blood.  The  total 
amount  of  urine  passed  in  the  twenty-four  hours  was  2010  c.c.  (67  ounces). 

An  examination  of  the  urine  three  weeks  later  showed  the  color  to  be  pale,  the  re- 
action acid,  the  specific  gravity  1014,  the  albumin  0.25-;-  of  one  per  cent.  It  contained 
hyaline  and  fine  granular  casts  of  small  diameter,  many  with  fat-globules  and  renal  cells 
adherent  ;  also  free  fat-globules,  fatty  and  granular  renal  epithelium,  some  normal  and 
abnormal  blood,  leucocytes,  and  squamous  cells.  The  casts  were  not  very  numerous, 
and  there  was  not  much  change  from  what  was  found  in  the  urine  three  weeks  pre- 
viously. At  this  time  the  urine  again  became  scanty,  and  the  oedema  and  pallor  re- 
turned, but  she  did  not  complain  of  any  discomfort.  An  examination  of  the  urine 
eight  weeks  later  showed  it  to  be  pale  and  cloudy,  the  reaction  acid,  the  specific  gravity 
1018,  and  that  it  contained  considerable  sediment,  and  albumin  0.25-r  of  one  per  cent. 
The  sediment  consisted  chiefly  of  hyaline  casts  of  medium  and  small  diameter,  many 
of  them  having  renal  cells  and  fat  adherent.  There  were  also  a  few  finely  granular 
casts,  considerable  abnormal  blood,  free  fat,  fatty  renal  cells,  epithelium,  leucocytes, 
and  occasionally  blood,  epiUielial,  and  fatty  casts. 

ACUTE   PYELITIS   AJSTD   PYELONEPHEITIS. 

Etiology. — Pyelitis  is  an  inflammation  of  the  mucous  membrane  lining 
the  pelvis  of  the  kidney.  After  the  pyehtis  has  lasted  for  a  time,  the  sub- 
stance of  the  kidney  may  be  involved  and  pyelonephritis  results.  The 
most  common  cause  is  the  excretion  of  uric  acid  by  the  kidney,  or  pehdc 
calcuH.  It  may  less  commonly  be  due  to  an  extension  upward  of  gon- 
orrhoea or  cystitis  from  the  ureter  and  bladder,  or  to  tuberculosis  of  the 
kidney,  or  to  malignant  growths.  There  is  also  an  infectious  form  which 
may  appear  in  the  acute  infectious  fevers,  such  as  scarlet  fever,  typhoid, 
neumonia,  or  malaria.  Pyelitis  due  to  a  local  cause  is  usually  unilateral. 
The  form  whicli  appears  as  a  complication  in  fevers  is  usually  bilateral. 
Some  cases  are  apparently  of  primary  infection.  These  are  usually  due 
to  the  bacillus  coli  communis. 

Pathological  Anatomy. — The  acute  cases  show  an  acute  catarrhal  in- 
flammation of  the  mucous  membrane  of  the  pelvis  of  the  kidney.  In 
chronic  cases  there  is  thickening  of  the  membrane  and  occasionally  a 
considerable  accumulation  of  pus.  In  pyelonephritis  the  suppurative 
process  extends  into  the  kidney  itself. 

Symptoms. — In  an  acute  attack  of  the  disease,  such  as  is  caused  by  uric 
acid  or  a  calculus,  there  are  often  local  pain,  chills,  and  fever.  Typical  at- 
tacks of  renal  colic,  with  vomiting,  pain,  and  intermittent  fever,  may  occur. 
Haematuria  may  be  an  early  symptom.  Micturition  is  frequent.  If  the  con- 
dition be  due  to  tuberculosis,  malignant  growths,  or  abscess  of  the  kidney, 
there  will  be  more  or  less  cachexia  and  emaciation,  and  there  may  be  local 
pain  and  tenderness.  Pyuria  is  often  the  only  symptom  in  the  cases  com- 
plicating acute  infectious  diseases,     Leucocytosis  is  generally  present. 


DISEASES    OF   THE   KIDNEYS.  869 

rrine. — The  diagnosis  is  made  from  the  examination  of  the  urine,  the 
characteristics  of  which  vary  accordiiig  to  the  extent  to  which  the  inflam- 
mation involves  the  parenchyma  of  the  kidney.  The  quantity  of  urine 
excreted  is  small.  The  color  is  high,  smoky,  or  blood-red,  according  to 
the  amount  o^  blood  present.  The  specific  gravity  is  generally  high  and 
the  total  solids  absolutely  diminished,  but  relatively  mcreased.  The  cjuan- 
tity  of  albumin  varies  from  a  trace  to  one-fourth  or  to  one-half  of  one  per 
cent.,  or  even  Mgher,  depending  upon  the  severity  of  the  involvement  of 
the  kidney  itself.  The  microscopic  examination  shows  sometimes  the 
w^hole  field  to  be  filled  with  pus-corpuscles,  at  other  times  the  pus  is 
in  clumps ;  there  are  also  present  small  round  cells  with  single  nuclei, 
from  the  pehis  or  from  the  kidney,  and  more  or  less  blood.  The  diag- 
nostic cell  of  pyelitis  is  the  "  caudate  cell."'  which  is  a  small  cell  about  the 
size  of  a  renal  cell,  havmg  a  single  nucleus  and  a  tail.  These  cells  come 
from  the  superficial  layers  of  the  pelvis  of  the  kidney,  and  may  disappear 
from  the  sediment  as  the  inflammatory  process  becomes  subacute  or 
clu-onic.  If  the  kidney  is  affected  there  are  casts  of  various  kinds,  hya- 
Ime,  granular,  epithelial,  and  blood.  The  casts  may  be  hard  to  find  if 
the  field  is  filled  mth  pus.  The  presence  of  tubercle  bacilli  in  the  sedi- 
ment, shown  by  appropriate  methods  of  staining,  establishes  the  diagnosis 
of  tuberculosis.  The  tuberculm  test  may  be  used  with  advantage.  ^\lien 
calculi  are  present,  they  usually  cause  local  pam  and  tenderness  and  hema- 
turia, and  occasionally  attacks  of  renal  colic.  In  the  freshly  passed  urine, 
uric  acid  is  often  present  in  the  sediment  in  the  form  of  irregular  spicu- 
lated  cr^'stals. 

DiAC4Xosis. — Xew  gro^^ihs  are  more  apt  to  produce  hemorrhages  than 
pus.  Pyelitis  may  usually  be  distmguished  from  cystitis  by  the  liistor^-, 
the  presence  of  caudate  and  round  pelvic  cells  in  large  numbers,  and  the 
evidences  of  renal  irritation.  In  cystitis,  on  the  other  hand,  there,  is  gen- 
erally vesical  pain  and  tenesmus  and  large  numbers  of  sc|uamous  and 
prostatic  cells.  It  maybe  confirmed  by  the  aid  of  the  cystoscope.  Cathe- 
terization of  the  ureters  in  older  children,  when  possible,  is  of  great  aid 
in  making  a  definite  diagnosis. 

Prognosis. — The  prognosis  depends  upon  the  cause.  In  malignant 
growths  it  is  fatal.  This  is  true  to  a  greater  or  less  degree  when  the  tubercle 
bacillus  is  the  cause  of  the  disease,  as  in  almost  every  case  tuberculosis  is 
present  somewhere  else  in  the  body.  When  uric  acid  or  a  calculus  is  the 
cause,  the  prognosis  is  more  favorable  under  appropriate  treatment. 

Treatment. — Uric  acid,  if  present,  should  be  treated  by  neutralizing  the 
acidity  of  the  urine,  by  placing  the  child  upon  a  mild  and  unirritating  diet, 
such  as  milk,  and  by  making  it  drink  fi'eely  of  water.  Potassium  citrate 
should  be  used  to  neutralize  excessive  acidity  of  the  urine,  or  benzoic  acid 
if  the  urine  is  alkaline.  Either  may  be  given  in  doses  of  from  0.12  to 
0.30  gramme  (2  to  5  grains)  three  or  four  times  daily  in  from  one  to  four 
ounces  of  water.     We  have  used  urotropine  or  cystogen  in  these  cases 


870  PEDIATRICS. 

with  very  beneficial  results.  0.3  gramme  (5  grains)  may  be  given  three 
times  a  day  to  a  child  of  four  or  five  years.  Operative  treatment  is  at 
times  called  for  when  a  calculus  is  present. 

OHBONIO  PYELITIS. 

Etiology. — Chronic  pyelitis  may  occur  from  a  number  of  causes,  such 
as  tuberculosis,  as  a  result  of  acute  pyelitis  from  any  cause,  from  irrita- 
tion of  crystals  and  calculi,  especially  when  the  outflow  of  the  urine 
through  the  ureter  is  obstructed,  and  from  a  movable  kidney. 

Symptoms. — The  symptoms  depend  largely  upon  the  cause  and  the 
manner  in  which  the  disease  develops.  There  are  often  no  symptoms  at 
all,  and  again  we  may  have  those  of  acute  obstruction  of  the  urine.  If 
there  is  retention  of  pus,  fever,  sweats,  leucocytosis,  and  renal  colic  result, 
and  the  condition  is  spoken  of  as  jyyonephrosis.  If  the  pus  is  discharged 
into  the  bladder,  these  symptoms  rapidly  subside,  returning  if  the  reten- 
tion recurs. 

Urine. — The  urine  is  somewhat  diminished  in  amount,  pale,  and  very 
turbid,  slightly  acid  in  reaction,  of  low  specific  gravity,  and  with  the 
normal  solids  diminished  both  absolutely  and  relatively.  The  albumin 
varies  from  a  slight  trace  to  0.1  per  cent.  The  sediment  is  chiefly  de- 
generated pus,  with  possibly  a  feAV  blood-globules.  Casts  of  large  diameter 
from  the  straight  tubules  are  generally  present,  but  are  hard  to  find. 
The  presence  of  crystals  may  enable  us  to  diagnosticate  a  pyelitis  due  to 
calculus,  but  concretions  may  exist  without  the  crystals  appearing  in  the 
urine.  In  all  cases  of  chronic  pyelitis  the  urine  should  be  examined  for 
tubercle  bacilli. 

Prognosis. — The  prognosis  depends  upon  the  cause.  If  the  cause  is 
removable  and  the  involvement  of  the  kidney  is  not  severe,  recovery  may 
be  expected. 

Treatment. — The  medical  treatment  is  essentially  the  same  as  in  acute 
pyelitis,  but  the  case  should  be  referred  to  the  surgeon  if  there  is  a 
reasonable  chance  of  removing  the  cause  by  operation.^ 

PBRINEPHIinTS. 

Perinephritis  is  an  inflammation  in  the  connective  tissue  about  the 
kidney.  It  may  end  in  resolution  or  suppuration.  It  has  been  con- 
founded not  infrequently  with  hip  disease  or  vertebral  caries.  The  most 
important  paper  on  perinephritis  in  children  was  published  in  1880  by 
Gibney,  who  reported  twenty-eight  cases. 

Etiology  and  Pathological  Anatomy. — Perinephritis  in  children  may 
be  secondary  to  suppuration  in  the  kidney,  such  as  results  from  calculi 
or  tuberculosis,  or  to  disease  of  the  suprarenal  capsules  or  to  trauma.  It 
is  more  frequently  primary.  The  cellular  tissue  about  the  kidney  becomes 
inflamed,  and  in  the  majority  of  cases  suppuration  occurs.  The  pus  may 
discharge  outward  in  the  ileo-costal  space,  or  into  the  pleura  or  bowel. 


DISEASES   OF   THE   KIDNEYS.  871 

Symptoms. — The  onset  may  be  acute  or  chronic.  In  the  acute  cases 
there  is  high  fever,  often  with  a  chill.  There  is  usually  gastric  disturbance, 
and  the  constitutional  symptoms  may  be  very  severe.  The  bowels  are 
constipated  at  times.  There  is  usually  local  pain  referred  either  to  the 
hip  or  small  of  the  back.  The  spine  is  painful  and  rigid,  and  tlie  leg  on 
the  same  side  is  drawn  up  as  the  movement  of  extension  is  productive 
of  pain.  General  movements  of  the  body  are  instinctively  avoided  by 
the  patient.  There  is  tenderness  and  resistance  in  the  lumbar  region, 
and  later  a  tumor  appears,  in  which  deep  fluctuation  may  sometimes  be 
obtained.  The  size  of  the  abscess  may  be  very  large.  The  cases  which 
discharge  into  the  pleura  are  usually  diagnosticated  as  empyema.  The 
character  of  the  urine  is  rarely  affected.  The  condition  runs  its  course 
in  from  a  few  weeks  to  six  months. 

Diagnosis. — Hip  disease  is  likely  to  be  confused  with  perinephritis,  but 
the  diagnosis  is  easy  after  careful  examination.  In  hip  disease  the  pro- 
cess is  much  more  chronic,  and  the  deformity  is  produced  insidiously. 
Moreover,  the  pain  is  lower  down,  and  there  is  tenderness  over  the  joints. 
There  is  limitation  of  all  the  movements  of  the  hip  instead  of  extension 
alone. 

Perinephritis  may  give  local  signs  similar  to  psoas  abscess  from  spinal 
caries,  but  the  characteristic  changes  and  deformity  of  the  lumbar  verte- 
brae are  absent. 

Perinephritis  may  be  confused  with  typhoid  fever  when  the  consti- 
tutional disturbance  is  severe  and  prolonged  and  the  local  signs  develop 
slowly. 

Prognosis. — The  primary  cases  almost  always  end  in  complete  re- 
covery. Peritonitis  from  rupture  of  the  abscess  is  the  most  serious 
complication. 

Treatment. — The  treatment  is  surgical.  Rest  in  bed  and  hot  local 
applications  are  first  indicated,  and  later  incision  with  free  drainage  of  the 
abscess. 

HYDRONEPHROSIS. 

Hydronephrosis  is  a  condition  in  which  the  pelvis  and  calyces  of  the 
kidney  are  dilated  with  fluid  as  a  result  of  an  obstruction  to  the  outflow 
of  urine. 

Etiology. — Hydronephrosis  may  be  congenital,  in  which  case  it  may 
be  due  to  constriction  of  the  ureter.  Both  kidneys  may  be  affected,  but 
usually  only  one  is  involved.  When  acquired  it  generally  affects  but  one 
kidney,  and  may  be  caused  by  obstruction  of  urine  either  from  above, 
such  as  may  occur  from  an  impacted  calculus  in  the  hilus  of  the  kidney 
or  in  the  urethra,  or  from  below  by  the  pressure  from  a  tumor  or  from  en- 
larged mesenteric  glands.  The  effects  are  mechanical,  and  are  due  to  the 
pressure  on  the  kidney  of  the  retained  fluid,  which  leads  to  the  gradual 
absorption  of  the  parenchyma  of  the  kidney.     These  tumors  sometimes 


872  PEDIATRICS. 

acquire  a  large  size.  They  are  frequently  associated  with  other  deformity 
or  degeneration  of  the  kidney. 

Symptoms. — The  main  symptom  of  hydronephrosis  is  the  presence 
of  an  abdominal  tumor  connected  with  the  kidney.  When  the  tumor  has 
grown  sufficiently  large,  fluctuation  can  usually  be  detected,  and  aspira- 
tion gives  a  fluid  which  ordinarily  contains  urea.  Subjective  symptoms  are 
usually  aJDsent  and  urinary  signs  are  rare.  If  only  one  kidney  is  affected, 
the  other  performs  the  function  of  both,  and  the  general  condition  of  the 
child  may  remain  good.  When  both  kidneys  are  affected,  life  is  usually  too 
short  for  the  development  of  a  tumor,  and  the  condition  is  not  recognized. 

Prognosis. — Bilateral  cases  are  usually  fatal  Avithin  a  year.  If  only 
one  kidney  is  involved  operation  gives  the  only  hope  of  relief. 

Treatment. — The  treatment  is  surgical.  Total  excision  of  the  kidney 
has  given  better  results  than  incision  and  drainage. 

MALIGNANT  GROWTHS  AND   ENLARGEMENT. 

Tumors  of  the  kidney  are  more  common  m  the  child  than  in  the 
adult.  They  are  almost  always  primary  and  usually  malignant.  The 
simple  adenomata  are  probably  equally  common  in  both,  but  the  child 
is  much  more  liable  to  carcinomata  and  sarcomata  than  is  the  adult. 
Sarcomata  are  the  most  common  in  the  first  five  years  of  life,  and  usually 
occur  in  one  kidney. 

Symptoms  and  Diagnosis. — The  diagnosis  depends  upon  the  recognition 
of  a  tumor  of  the  kidney,  the  haematuria,  and  the  progressive  emaciation 
and  cachexia  Avhich  arise.  At  times  there  is  pain,  but,  as  a  rule,  pain  is 
absent.  The  urine  sometimes  gives  evidence  of  a  pyelo-nephritis  ;  hasma- 
turia  and  albuminuria  usually  occur  at  intervals  late  in  the  disease,  at  a 
time  when  the  tumor  can  be  felt  through  the  abdominal  wall.  The  tumors 
are  frequently  of  large  size  and  rapid  growth.  They  may  cause  symptoms 
y  compression  of  the  lungs,  vena  cava,  or  bowels.  Ascites  is  sometimes 
present,  and  very  rarely  general  peritonitis.  Some  of  the  characteristics 
of  a  tumor  of  the  kidney  are  that  it  is  located  in  the  hypogastric  and 
lumbar  regions,  is  deep-seated,  and  is  not  so  commonly  to  be  felt  in  the 
umbilical  region  as  are  tumors  of  the  retro-peritoneal  glands.  The  tumor 
is  irregularly  rounded,  and  usually  does  not  have  a  well-marked  border, 
such  as  is  found  in  enlargement  of  the  spleen  and  liver.  In  these  cases 
of  sarcomata  of  the  kidney  the  health  at  first  is  often  not  much  affected, 
but  there  are  progressive  emaciation  and  enlargement  of  the  abdomen, 
commonly  without  pain.  Malignant  growths  of  the  kidney  may  be  con- 
fused with  hydronephrosis. 

Prognosis. — The  prognosis  is  very  unfavorable,  although  temporary 
relief  is  sometimes  obtained  by  means  of  surgical  interference. 

Treatment. — The  treatment  is  essentially  operative.  The  total  mor- 
tality of  the  operation,  including  cases  of  recurrence  with  death,  is 
over  seventy-five  per  cent. 


DISEASES   OF   THE   BLADDER   AND   GENITALS.  873 

DISEASES  OF  THE  BLADDER  AND  GENITALS. 

ACUTE   CYSTITIS. 

Acute  cystitis  is  not  a  common  affection  in  infancy  and  cliildliood. 

Etiology. — It  may  be  caused  by  a  vesical  calculus,  by  irritants,  such 
as  turpentine,  and  also  occasionally  by  the  extension  of  infection  through 
the  genital  tract,  but  this  is  less  common  than  in  adults.  It  is  not  an 
infrequent  complication  of  typhoid  fever  and  many  other  diseases  from 
direct  infection  by  the  bacteria  which  are  eliminated  by  the  urine.  Gon- 
orrhoea and  infections  by  the  pyogenic  organisms  are  direct  causes  of 
acute  cystitis.     It  is  more  common  in  girls  than  in  boys. 

Symptoms. — In  children  the  chief  symptom  is  frequent  and  painful 
micturition.  This  local  symptom  is  usually  accompanied  by  fever,  which 
may  be  high,  and  by  general  symptoms  of  malaise,  fretfulness,  and  crj-ing 
from  vesical  pain  and  tenesmus.  The  urine  is  passed  in  small  quantities, 
and,  as  a  rule,  is  of  a  reddish  color  at  first,  and  gradually  becomes  of  a 
lighter  color.  The  specific  gravity  is  high.  When  freshly  passed  it  is 
acid,  but  it  quickly  becomes  alkaline ;  there  are  a  heavy  sediment  and  a 
trace  of  albumin.  Microscopic  examination  shows  chiefly  pus  in  large 
quantities,  squamous  epithehum,  and  some  blood.  To  establish  the  diag- 
nosis in  females  it  is  sometimes  necessary  to  examine  a  catheter  speci- 
men. In  infants  the  symptoms  are  so  mild  that  the  condition  is  often 
unsuspected. 

PROGNOsis.^The  prognosis  of  acute  cystitis  is  good  after  the  removal 
of  the  cause. 

Treatment. — The  especial  cause  of  the  attack  must  be  looked  for,  and 
removed  if  possible.  The  child  should  be  kept  perfectly  quiet  in  bed, 
and  should  be  made  to  drink  a  great  deal  of  water.  The  diet  should  be 
of  milk.  In  the  acute  cystitis  occurring  in  the  course  of  typhoid  fever, 
urotropine  in  doses  of  from  0.06  to  0.32  gramme  (1  to  5  grains)  four  times 
a  day  acts  almost  as  a  specific  in  from  four  to  seven  days.  In  cystitis  due 
to  other  causes  it  is  not  so  serviceable,  except  as  a  preventive  of  fer- 
mentation of  urine  within  the  bladder.     Sedatives  should  be  used  freely. 

CHRONIC  CYSTITIS. 

Etiology. — Chronic  cystitis  may  be  caused  in  children,  as  in  adults,  by 
a  vesical  calculus,, by  foreign  bodies  ui  the  bladder,  by  tumors,  by  papil- 
lomata,  and  by  tuberculosis.  The  nuclei  of  the  calculi  are  generally 
composed  of  uric  acid,  upon  which  phosphates  are  precipitated  in  alkaline 
urine,  and  this  deposition  is  favored  by  the  accompanying  catarrhal  in- 
flammation. 

Symptoms. ^-Micturition  is  frequent  and  at  times  painful.  Later  there 
may  be  a  constant  dribbling  of  urme,  giving  rise  to  an  offensive  ammo- 
niacal  odor  and  causing  irritation  about  the  genitals.  When  there  is  a 
calculus  in   the  bladder  the  stream  is  often  suddenly  interrupted  durmg 


874  PEDIATRICS. 

micturition,  and  the  pain  is  more  severe.  Prolapse  of  tlie  rectum  is  not 
uncommon  with  stone.  In  addition  to  these  local  symptoms  there  are 
general  symptoms  of  anaemia  and  loss  of  weight.  The  urine  is  ammo- 
niacal,  offensive  in  odor,  and  turbid,  has  a  heavy  ropy  sediment,  and 
contains  a  trace  of  albumin.  The  sediment  should  be  examined  as  soon 
as  possible  after  the  urme  is  passed,  because  the  ammonia  which  is 
produced  from  the  urea  disintegrates  the  cells.  The  examination  will 
show  a  large  quantity  of  pus,  some  blood,  bladder-epithelium,  and  crystals 
of  triple  phosphate  and  urate  of  ammonium.  Tubercle  bacilli  may  be 
found  in  the  urine  in  tuberculosis  of  the  bladder,  but  a  prolonged  and 
careful  search  is  often  necessary. 

Prognosis. — ^The  prognosis  of  chronic  cystitis  depends  upon  the  cause, 
upon  the  length  of  time  during  which  the  disease  has  persisted,  and  the 
presence  or  absence  of  a  secondary  infection  of  the  kidney. 

Treatment. — The  urine  should  be  diluted  by  giving  distilled  water  in 
large  amount.  It  may  be  rendered  less  irritating  by  such  drugs  as  salol 
and  buchu,  and  less  alkaline  by  benzoate  of  sodium.  Urotropin  given  by 
the  mouth  has  yielded  excellent  results  by  disinfecting  the  urine  in  the 
bladder  and  checking  alkaline  fermentation.  Washing  out  the  bladder 
with  weak  solutions  of  permanganate  of  potash,  creolin,  boracic  acid,  or 
lysol  is  of  use  in  many  cases,  and  local  applications  may  be  made  in  tuber- 
culosis of  the  organ.  Operative  treatment  is  indicated  when  a  calculus  is 
causing  the  disturbance. 

At  times  it  is  exceedingly  difficult  to  determine  by  the  general  symptoms 
whether  or  not  a  calculus  is  present  in  the  bladder.  The  following  case 
may  be  cited  as  an  illustration  : 

A  boy,  seven  years  old,  began  to  have  pain  of  a  spasmodic  character  in  the  region 
of  the  bladder  during  micturition.  In  connection  with  the  pain  there  was  a  sudden 
stoppage  of  the  flow  of  the  urine  and  a  bearing-down  feeling  in  the  rectum.  These 
symptoms  simulated  those  of  a  vesicle  calculus  so  closely  as  to  render  a  differential 
diagnosis  very  difficult.  The  boy  was  of  a  nervous  temperament,  and  was  rather 
anaemic,  but  otherwise  was  well  and  strong.  Nothing  abnorrnal  was  detected  about 
the  prepuce  or  the  rectum.  The  pain  was  so  annoying  and  caused  so  much  trouble 
that  it  was  deemed  advisable  to  have  the  bladder  examined  for  stone.  An  examination 
was  made,  but  nothing  abnormal  was  detected.  After  this  a  decided  improvement  took 
place,  apparently  connected  with  the  passing  of  the  sound,  and  the  boy  recovered 
entirely  after  remaining  at  home  from  school  for  a  few  weeks  and  having  daily  exercise 
in  the  open  air. 

■VTJLVO-VAGINinS. 

Vulvo-vaginitis  is  a  very  common  affection  in  little  girls.  It  arises 
from  a  variety  of  irritations,  one  of  which  is  the  pxyuris  vermicularis.  In 
a  very  large  number  of  cases  the  gonococcus  of  Neisser  has  been  found 
in  the  purulent  secretion.  The  gonococcus  Avas  found  in  all  of  six  cases 
lately  treated  at  the  Boston  Children's  Hospital.  The  disease  may  also 
arise  in  children  who  are  very  much  debilitated,  and  is  met  with  at  times 


DISEASES   OF   THE   BLADDER   AND   GENITALS.  875 

in  scarlet  fever  and  in  measles.  Again,  it  is  not  infrequent  in  anaemic 
girls,  in  whom  it  occurs  without  any  apparent  cause. 

Pathological  Anatomy. — The  labia  are  reddened  and  are  more  or  less 
swollen.  There  is  a  thick,  purulent  discharge  of  a  greenish-yellow  color, 
usually  offensive.  At  times  there  is  more  or  less  excoriation  of  the  inner  sur- 
faces of  the  labia.  The  inguinal  glands  may  be  slightly  enlarged  and  tender. 
The  urethra  is  often  involved  in  the  irritation,  and  is  swollen  and  red. 

Symptoms. — There  may  be  some  fever  in  the  early  stag'es  of  vulvo- 
vaginitis. Smartmg  and  burning  are  usually  complained  of,  but  at  times 
the  staining  of  the  clothmg  first  calls  attention  to  the  disease.  The 
children  commonly  become  pale  if  the  disease  persists  for  some  time. 
Micturition  is  painful  and  frequent  in  some  cases,  and  the  disease  is  one 
of  the  many  causes  of  dysuria.  In  many  cases  the  cliildren  appear  to  be 
quite  well,  with  the  exception  of  the  local  condition.  A  positive  diagnosis 
of  gonorrhoea  is  only  possible  by  means  of  a  microscopic  examination  of 
the  discharge  after  staining  by  Gram's  method. 

Prognosis. — The  prognosis  is  good,  but  the  disease  is  apt  to  be  jDro- 
longed  for  several  weeks  or  months.  Complications  may  arise  from  the 
infection  of  the  bladder,  uterus.  Fallopian  tubes,  inguinal  glands,  joints, 
or  conjunctivae.  Infection  of  the  conjunctivee  is  common,  infection  of  the 
uterus  and  other  organs  is  much  less  so. 

Treatment. — Local  applications  to  the  vagina  constitute  the  only  satis- 
factory form  of  treatment.  This  is  difficult  m  young  children,  but  may 
be  accomplished  with  a  soft  rubber  catheter  or  with  a  soft  rubber  ear- 
syringe.  Such  solutions  as  boracic  acid  1  to  40,  corrosive  sublimate  1  to 
5000,  or  creolin  1  to  500,  may  be  used.  In  some  severe  cases  local  appli- 
cations of  nitrate  of  silver,  1  or  2  per  cent.,  or  of  protargol,  2  to  4  per  cent., 
may  be  necessary.  The  labia  should  be  kept  separated  by  absorbent  cot- 
ton, and  the  parts  kept  dry  and  covered  with  some  mild  dusting-powder. 
Absolute  cleanliness  must  be  observed,  to  prevent  infection  of  the  eyes  and 
of  other  persons.  The  parts  should  be  protected  with  compresses  held  in 
place  by  a  bandage,  which  should  be  worn  all  the  time,  and  the  com- 
presses should  be  frequently  changed  and  burned.  The  towels  used  for 
the  patient  should  not  be  left  lying  about,  and  should  be  carefully  dis- 
infected. Tonic  treatment  is  sometimes  indicated.  The  urine  should 
be  kept  dilute,  in  order  to  avoid  irritating  the  inflamed  surfaces,  and 
any  complicating  cystitis  should  be  treated.  Durmg  the  active  stage  of 
the  disease  the  child  should  be  kept  as  quiet  as  possible,  and  on  a  diet 
of  milk. 

When  the  vulvo-vaginitis  is  caused  by  the  oxyuris  vermicularis, 
especial  care  shoLild  be  given  to  eradicating  the  parasite  from  the  rectum, 
as  described  on  page  832.  After  this  has  been  done,  the  vagina  is  readily 
freed  from  the  parasite  by  using  an  injection  of  Avarm  sweet  oil,  which  is 
to  be  allowed  to  remain  for  three  or  four  minutes,  the  vagina  then  being 
syringed  out  with  warm  water. 


876  PEDIATRICS. 

ORCHmS. 
Orchitis,  or  inflammation  of  the  testis  proper,  occasionally  results  from 
direct  injury,  much  more  rarely  from  infection  in  gonorrhoea,  syphilis,  and 
tuberculosis.  When  present  it  is  commonly  accompanied  by  hydrocele. 
The  orchitis  which  so  commonly  follows  mumps  m  the  adult  is  much  less 
common  in  children.  The  treatment  consists  in  support  of  the  testicle  by 
means  of  a  suspensory  or  of  a  bandage. 

EPrDiDYMrns. 

Acute  epididymitis  may  be  caused  by  trauma  or  by  any  irritation  of 
the  mucous  membrane  of  the  urethra.  In  this  disease  the  whole  scrotum 
is  apt  to  be  hot  and  tender,  and  the  child  is  in  great  pain.  The  epi- 
didymis is  much  enlarged  and  exc|uisitely  tender,  and  pushes  the  testis 
forward.  The  cord  is  often  implicated,  becoming  enlarged  and  painful 
on  pressure. 

The  treatment  should  be  energetic,  as,  owing  to  the  swelling  of  the 
tissues  about  the  testicle,  there  may  be  so  much  pressure  that  the  gland 
will  be  seriously  damaged,  although  the  subsequent  atrophy  may  not  de- 
clare itself  for  a  considerable  time.  The  child  should  be  kept  upon  his 
back  in  bed,  the  bowels  freed  with  a  cathartic,  and  a  series  of  hot  poultices 
kept  upon  the  scrotum.  In  all  inflammations  of  the  testis  or  epididymis 
the  scrotum  should  be  placed  in  such  a  position  that  the  lower  end  of  the 
testicle  points  upward. 

TUMORS  OP  THE  TESTICLE. 
In  addition  to  tubercular  disease  of  the  testis,  tumors  may  be  found 
in  infancy  and  in  early  childhood.  These  may  be  congenital  or  acquired. 
The  congenital  tumors  are  very  rare,  and  are  usually  of  the  dermoid 
variety.  The  most  common  of  the  acquired  tumors  are  carcinomata  and 
sarcomata,  which  are  very  malignant.  The  rapid  growth  and  the  large 
~size  of  this  variety  usually  render  the  diagnosis  easy. 

PHIMOSIS. 
In  early  life  there  appears  to  be  a  physiological  adhesion  of  the  pre- 
puce to  the  glans  penis.  As  the  child  grows  older  these  adhesions 
normally  disappear.  When  the  adhesion  between  the  prepuce  and  the 
glans  remains  permanent  and  the  prepuce  is  very  tight,  the  condition  gives 
rise  to  various  symptoms.  Thus  the  escape  of  the  urine  may  be  me- 
chanically hindered,  and  the  urine  collecting  behind  the  glans  may  give 
rise  to  irritation.  Smegma  is  also  apt  to  collect  around  the  corona.  In 
this  way  an  inflammatory  condition  of  the  prepuce  (posthitis)  or  of  the 
glans  (balanitis)  may  arise.  As  a  result  of  this  there  is  swelling,  and 
micturition  is  painful  and  difficult.  In  addition  to  these  local  symptoms 
many  secondary  disturbances  arise  from  the  local  reflex  irritation.  Among 
these  are  nervous  phenomena  of  greater  or  less  degree,  such  as  insomnia 
or  convulsions.     Phimosis  may  lead  to  enuresis  and  masturbation. 


DISEASES   OF   THE   BLADDER   AND   GENITALS.  877 

In  all  cases  of  phimosis  which  give  rise  to  symptoms  of  irritation  local 
treatment  is  indicated,  and  may  be  by  dilatation,  incision,  or  circumcision  ; 
the  latter  is  the  most  radical  and  produces  the  best  results  for  com- 
plete relief  from  the  morbid  condition.  In  all  cases,  even  if  the  phimosis 
is  very  slight,  mechanical  interference  should  be  persisted  in  until  absolute 
cleanliness  can  be  secured,  for  in  this  way  only  will  entire  relief  from  the 
local  and  reflex  symptoms  be  obtained. 

ENURESIS. 

Enuresis  (incontinence  of  urine)  is  a  condition  in  which  there  is  an 
involuntary  discharge  of  the  urine.  It  may  be  continuous  or  periodic. 
It  may  also  be  diurnal,  nocturnal,  or  both.  It  is  of  very  frequent  occur- 
rence in  infancy  and  early  childhood.  It  is  a  symptom  rather  than  a 
disease,  and  in  most  cases  is  a  true  neurosis.  During  the  first  year  of  life 
the  infant  has  not  learned  to  assume  control  of  the  mechanism  of  mictu- 
rition, but  during  the  second  year  this  control  is  usually  attained  at  an 
earlier  or  a  later  period  according  to  the  individual. 

Etiology. — The  causes  of  enuresis  may  be  organic  or  functional,  the 
latter  in  all  probability  being  very  commonly  of  a  reflex  nature. 

Org-anic  Enuresis. — The  organic  causes  comprise  such  malforma- 
tions as  small  ureters,  a  small  bladder,  exstrophy  of  the  bladder,  and 
hypospadias.  Enuresis  may  also  be  caused  by  central  lesions  of  the  brain 
and  cord,  such  as  tumor  of  the  brain,  idiocy,  or  injury  to  the  cord.  The 
prognosis  and  treatment  of  these  organic  cases  of  enuresis  vary  according 
to  the  conditions  which  cause  them,  and  need  not  be  considered  here. 

Functional  Enuresis. — In  many  cases  the  children  are  of  a  highly 
nervous  temperament,  but  at  times  they  do  not  show  any  nervous  symp- 
toms. As  has  been  stated  by  Rachford  in  an  admirable  paper  on  this 
subject,  this  condition  may  depend  upon  (1)  irritable  and  unstable  nerve- 
centres,  (2)  ansemia  with  malnutrition,  and  (3)  reflex  stimulation  of  certain 
nerve-centres  in  the  lumbar  cord.  The  longitudinal  and  circular  mus- 
cular fibres  of  the  bladder,  which  by  theu"  contraction  empty  the 
bladder,  are  innervated  by  sensory  and  motor  nerves  from  the  lumbar 
region  of  the  cord,  and  the  external  sphincter  in  the  prostatic  portion 
of  the  urethra,  which  by  its  contraction  prevents  the  escape  of  urine 
from  the  bladder,  is  also  innervated  by  sensory  and  motor  nerves  from 
the  lumbar  cord.  The  researches  of  Von  Zeissl  show  the  manner  in 
which  reflex  causes  may  act  in  starting  or  checking  the  flow  of  the  urine. 
Thus,  a  reflex  carried  to  the  proper  centre  in  the  lumbar  cord  would, 
through  the  motor  fibres  of  the  erector  nerve,  contract  the  muscular  coat 
of  the  bladder,  and  through  the  inhibitory  fibres  of  the  same  nerve  relax 
the  sphincter  vesicae.  In  this  manner  the  urine  which  is  being  expelled 
by  the  contracting  bladder  is  allowed  to  pass  without  hinderance  through 
the  relaxed  sphincter  vesicae.  It  is  also  to  be  remembered  that  the  act 
of  urination  is  in  part  under  the  control  of  the  will.     Admitting  these 


878  PEDIATRICS. 

anatomical  and  psychical  facts,  it  is  easily  understood  how  the  causes 
which  produce  enuresis  may  act  in  two  ways :  either  directly  on  the 
centres  in  the  lumbar  cord,  making  them  more  irritable  or  unstable,  and 
in  that  way  increasing  their  reflex  excitability,  or  indirectly  through  ex- 
a^erated  reflex  causes  that  affect  both  acceleratory  and  mhibitory  influ- 
ences sent  to  the  bladder.  These  influences  may  be  psychic,  originating 
in  the  brain,  or  may  be  the  result  of  external  irritation  originating  in  or 
near  the  bladder  itself. 

There  is  also  during  childhood  a  lack  of  development  of  the  centres 
of  inhibitory  reflex  acts,  and  in  this  way  the  muscular  fibres  of  the 
bladder,  ha^ing  no  inhibitory  restraint,  are  excited  to  action  by  even  so 
slight  a  reflex  cause  as  a  small  quantity  of  urine  in  the  bladder.  For  this 
reason  enuresis  is  a  normal  condition  during  infancy,  and  ceases  when  the 
child's  inhibitory  mechanism  is  more  developed  (Soltmann).  The  inhibi- 
tory influence  of  the  will  is  in  abeyance  during  deep  slumber,  and  noc- 
turnal incontinence  is  therefore  more  frequent  than  diurnal.  In  any 
diseases  which  are  accompanied  by  aneemia  and  malnutrition  the  reflex 
irritability  of  the  lumbar  nerve-centres  is  much  mcreased  and  enuresis 
may  result.  Reflex  enuresis  may  be  caused  by  irritation  in  any  portion 
of  the  genito-urinary  tract,  as  by  a  vesical  calculus,  cystitis,  vuhitis, 
phimosis,  very  acid  urine,  and  over-filling  of  the  bladder,  as  in  diabetes, 
or  by  an  irritation  of  some  neiglibormg  part,  such  as  may  arise  from  a 
fissure,  poh^jus.  or  the  oxyuris  vermicularis  in  the  rectum. 

Symptoms. — As  a  symptom,  enuresis  is  simply  the  involuntari'  empty- 
ing of  the  bladder. 

Prognosis. — The  prognosis  of  enuresis  varies  greatly,  accordmg  to  the 
cause  and  the  individual.  It  is  usually  hopeless  when  it  depends  on 
disease  of  the  brain  or  cord.  In  a  large  number  of  cases  the  enuresis 
lasts  for  only  a  short  time,  but  in  some  cases  it  may  continue  throughout 
~  childhood ;  almost  invariably,  however,  it  ceases  between  the  twelfth  and 
the  fourteenth  year.  The  cases  in  wliich  enuresis  does  not  chsappear  at 
puberty  are  nearly  always  in  girls. 

Treatment. — The  treatment  of  this  functional  form  of  enuresis  is  often 
prolonged  and  very  unsatisfactory.  According  to  our  experience,  in  quite 
a  number  of  cases  the  disease  is  intractable  and  is  not  affected  by  any 
treatment  whatever,  the  individual  finally  recovering  -^vithout  treatment. 
Sometimes  a  habit  of  incontinence  seems  to  have  formed  which  continues 
after  the  removal  of  the  original  exciting  cause.  After  a  careful  examination 
has  shown  that  no  malformation  or  central  nen^ous  lesion  is  present,  the 
urine  should  be  examined,  to  determme  if  it  is  abnormally  acid.  "When 
this  is  found  to  be  the  cause  of  the  irritation,  a  rapid  cure  can  be  effected 
in  some  cases  by  simply  diluting  the  urine.  In  females,  especially  when 
there  is  irritation  around  the  meatus  urinarius,  local  applications  are  of 
great  service,  and  in  some  cases  dilatation  of  the  urethra  will  produce  a 
permanent  cure.     When  phimosis  is  present,  relief  has  sometimes  been 


DISEASES    OF    THE    BLADDER   AND    GENITALS.  379 

obtained  by  circumcision.  The  bowels  should  be  regulated,  little  or  no 
fluid  should  be  given  after  five  p.m.,  and  it  is  well  to  have  the  child  pass  its 
water  just  before  going  to  sleep,  and, to  arouse  it  in  the  middle  of  the  night 
in  order  that  it  may  empty  its  bladder.  The  foot  of  the  bed  should  be 
raised,  in  order  that  the  urine  shall  not  irritate  the  neck  of  the  bladder. 
There  is  no  especial  drug  which  in  our  experience  can  be  relied  upon  to 
cure  enuresis.  Occasionally  one  may  effect  a  complete  cure  of  enuresis 
by  the  combined  use  of  large  doses  of  the  tincture  of  nux  vomica,  4  to  8 
minims  for  a  child  of  4  or  5  years,  and  of  the  tincture  of  belladonna,  8  to 
15  minims,  three  times  a  day.  Attention  to  general  hygiene  is  important. 
Plenty  of  sleep  and  a  simple  diet  should  be  insisted  upon.  Punishment  of 
the  child  is  usually  harmful,  and  should  never  be  allowed.  When  the 
children  are  anasmic  and  debilitated,  iron  and  nux  vomica  are  indicated. 
Faradism  apphed  to  the  perineum  or  to  the  base  of  the  sacrum  and  to 
the  symphysis  pubis  is  in  some  cases  beneficial.  If  the  bladder  is  .con- 
tracted, daily  dilatation  up  to  the  normal  size  with  Avarm  water  may  be 
very  effectual.  Epidural  injection  of  normal  salt  solution  has  been  tried 
with  success  in  a  number  of  recently  reported  cases. 

MASTURBATION. 

Masturbation  is  one  of  tlie  injurious  habits  of  early  life.  It  is  most 
frequently  practised  during  the  later  periods  of  childhood,  especially  be- 
tween the  tenth  and  fifteenth  years.  It  may,  however,  become  a  habit  at 
any  age,  even  in  infants  of  one  year. 

The  inciting  cause  may  be  some  local  irritation,  such  as  intestinal  j^ara- 
sites,  concentrated  and  very  acid  urine,  phimosis,  balanitis,  vaginitis,  and 
a  long  prepuce.  It  may  also  be  inculcated  by  the  indiscreet  handling  of 
the  genitals  by  nurse-maids.  Not  infrequently  the  habit  is  started  from 
imitation  of  other  children. 

There  are  no  characteristic  symptoms  by  which  one  can  judge  as  to 
whether  a  child  is  a  victun  of  tliis  habit.  The  pallor,  anemia,  dark  rings 
under  the  eyes,  headaches,  and  embarrassment  which  are  sometimes  men- 
tioned as  distinctive  signs,  are  common  to  so  many  other  conditions  that 
they  are  not  sufficient  evidence  on  which  to  make  a  diagnosis.  Mastur- 
bation is  stated  by  some  writers  to  be  a  dfrect  cause  of  insanity. 

The  diagnosis  of  masturbation  should  only  be  made  when  the  child 
has  actually  been  observed  to  practise  the  habit  on  several  occasions. 

The  treatment  in  young  infants  consists  in  mechanical  restraint,  the 
hands  and  legs  being  so  tied  that  the  act  becomes  impossible.  In  older 
children  strict  surveillance  should  be  kept.  Punishment  should  be 
avoided.  Moral  persuasion,  diversion  of  the  mind,  exercise,  bathing  with 
cold  water,  diet,  and  general  hygiene  are  the  main  points  in  the  treat- 
ment. In  serious  cases  the  bromides  may  be  given,  Hypnotism  has 
proved  very  beneficial  in  many  of  these  cases. 


DIVISION    XV. 

THE  BLOOD.    THE  LYMPH-NODES.    THE  DUCTLESS 

GLANDS. 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD. 

The  blood  does  not  merely  absorb  the  waste  material  from  the  tis- 
sues and  carry  fresh  oxygenated  material  to  replace  it ;  it  plays  a  far 
greater  part  than  this  in  the  economy,  and  is  intimately  connected  with 
many  diseases,  both  through  its  corpuscular  elements   and  its   serum. 

Plate  XV.,  facing  page  884,  sliows  all  the  principal  normal  and  abnormal 
cells  occurring  in  the  blood  in  early  life.  The  different  types  of  anaemia 
are  characterized  by  a  combination  of  the  different  cells  in  varying  pro- 
portions, and  by  becoming  familiar  with  their  microscopic  appearance,  and 
then  in  a  given  case  by  calculating  the  percentages  of  the  different  cells 
which  are  present  we  have  a  very  valuable  aid  in  diagnosis. 

THE  BLOOD  IN  NORMAL   CONDITIONS. 

There  are  certain  general  characteristics  which  must  be  recognized 
when  we  are  dealing  with  human  beings  in  the  earlier  stages  of  their 
-development. 

These  characteristics  merely  impress  upon  us  that  the  blood,  like  the 
various,  organs  and  tissues,  changes  by  a  process  of  development  from  the 
foetal  to  the  developed  condition  of  adult  life.  It  is  therefore  necessary  to 
take  into  consideration  the  age  and  stage  of  development  of  the  individual 
whose  blood  we  are  examinmg  before  we  can  state  that  such  a  blood  is 
normal  or  abnormal.  For  instance,  just  as  it  would  be  abnormal  for  the 
anterior  fontanelle  to  be  closed  at  the  sixth  month  and  unclosed  at  the 
twentieth  month,  so  it  would  be  abnormal  for  the  blood  of  an  infant  in 
the  early  weeks  of  life  to  show  the  same  ratio  of  leucocytes  to  erythro- 
cytes as  would  occur  in  adult  life,  or  for  the  leucocytes  to  show  the  percent- 
age of  lymphocytes  and  polynuclear  neutrophiles  in  the  same  proportion  as 
at  a  later  period.  In  fact,  what  we  have  already  stated  concerning  the 
different  stages  of  physical  development  holds  true  in  the  case  of  the 
blood.  What  can  be  considered  normal  and  physiological  at  one  period 
becomes,  if  it  lasts  into  another  period,  abnormal  and  significant  of  dis- 

880 


THE   BLOOD    IX   LXFAXCY   AXD    CHILDHOOD.  881 

ease.  In  order  to  understand,  therefore,  the  diseased  conditions  of  the 
blood  we  must  remember  what  is  normal  at  each  period.  We  wih  next 
consider  the  normal  condition  of  the  blood  at  birth  and  its  various  stages 
of  development. 

Amount  of  Blood  at  Birth. — ^T\^elcker  states  that  the  total  amount  of 
blood  at  birth  is  one-nineteenth  of  thebody-weight.  His  opinion  is  based 
on  the  examination  of  a  poorly  developed  infant,  in  which  the  umbilical 
cord  was  ligatured  immediately  at  birth. 

Schueckmg  places  the  amount  at  one-fifteenth  of  the  body-weight, 
from  an  examuiation  of  five  full-term  infants,  without  expressing  the 
blood  from  the  placenta,  and  mth  immediate  ligature  of  the  cord.  When 
the  cord  was  tied  later,  and  the  so-called  "resen-e"  blood  was  expressed 
from  the  placenta,  the  percentage  rose  to  one-ninth.  In  adults  the  re- 
lation of  the  blood  to  the  body-weight  is  stated  to  be  one-thu-teenth.  All 
authors  agree  that  there  is  a  temporary  gain  in  the  amount  of  blood  when 
the  cord  is  tied  late. 

Reactiox. — The  reaction  of  the  blood  at  birth  is  always  alkalme. 

Color. — The  color  is  found  to  be  darker  in  the  capillaries  during  the 
first  few  days  than  at  any  other  time. 

Specific  Gravity. — At  birth  the  specific  gravity  of  the  blood  is  about 
1065,  and  this  does  not  vary  for  the  first  few  weeks.  Then  for  a  varying 
number  of  months  there  is  a  constant  diminution,  decreasing  in  boys  to  as 
low  as  1048,  and  in  girls  to  1050.  It  then  gradually  rises,  till  at  the  end 
of  the  first  year  it  has  reached  the  normal  average  of  1052  to  1055 
(Hock  and  Schlesinger).  The  specific  gravity  does  not  seem  to  be  in- 
fluenced by  the  number  of  red  or  white  corpuscles,  food,  rest,  exercise,  or 
other  causes,  but  depends  directly  upon  the  amount  of  h^moglobm.  As 
a  whole,  the  specific  gravity  is,  apart  from  physiological  variations,  very 
constant  in  the  same  individual,  and  remains  for  weeks  and  months  the 
same.  Hock  and  Schlesinger  place  the  greatest  twenty-four-hour  varia- 
tion at  0.00025.  The  appearance  of  the  child's  skin  is  not  an  index  to 
the  specific  gravity  of  the  blood  or  to  the  amount  of  the  htemoglobin. 
Children  often  appear  antemic  without  any  especial  alteration  in  either  of 
these  conditions. 

HiMOGLOBix. — The  hemoglobin  is  found  to  be  less  firmly  bound  to 
the  red  corpuscle  in  the  infant  at  term  than  it  is  in  adults.  It  is,  however, 
proportionately  greater  in  amount  at  birth  than  m  adult  life,  and  is  due  to 
an  actual  increase  in  the  percentage  present  in  the  individual  erythrocytes. 
The  haemoglobin,  like  the  specific  gravity,  which  is  closely  dependent  upon 
it,  reaches  its  maximum  at  birth.  Starting  at  100  or  104,  or  occasionally 
as  high  as  125  to  130  per  cent.,  it  falls  rapidly  to  its  minimum  in  the  first 
three  weeks  of  life  (Hock,  Schlesinger,  Widowitz,  Schmaltz,  and  Ham- 
merschlag).  The  lowest  percentage  that  has  been  found  is  about  fifty-five 
per  cent.  The  average  figure  for  infants  and  children  is  seventy  per  cent. 
It  reaches  this  level  at  about  the  sixth  month  and  persists  with  a  slight 

56 


882  PEDIATRICS. 

tendency  to  rise  until  the  end  of  the  second  year,  and  then  gradually 
increases  until  at  the  end  of  the  sixth  year  the  adult  standard  has  been 
reached.  The  percentage  of  haemoglobin  varies  greatly  not  only  between 
different  individuals,  but  also  in  the  same  individual,  which  may  explain 
the  great  discrepancy  in  the  figures  given  by  various  authorities.  Haemo- 
globin is  more  abundant  in  boys  than  in  girls. 

Red  Corpuscles  {erythrocytes). — All  authors  agree  that  there  is  a  large 
number  of  red  corpuscles  at  birth,  and  also  that  an  increase  occurs  in  the 
first  twenty-four  hours.  As  regards  the  actual  number  in  a  cubic  milli- 
metre of  blood'  there  is  much  diversity  of  opinion.  Hayem  has  found  a 
larger  number  at  the  moment  of  birth  than  in  the  mother's  blood,  and 
gives  as  an  average  5,350,000 ;  Shiff  says  5,800,000.  The  increase  after 
birth  is  only  seeming,  according  to  Shiff,  and  is  due  to  a  loss  of  fluid  and 
consequent  concentration  of  the  blood.  From  the  second  day  the  red 
cells  normally  diminish,  and  fall  eventually,  according  to  Lepine,  Jerrard, 
and  Schlemmer,  to  5,000,000.  Karnizki  in  his  recent  work  gives  the 
average  number  of  erythrocytes  under  one  year  as  5,583,744,  and  for  the 
whole  of  childhood  as  5,892,000.  These  figures  agree  substantially  with 
those  of  Schwinge  and  Gundobin,  and  are  considerably  higher  than  those 
which  were  formerly  accepted.  There  is  much  greater  variation  in  size 
in  the  red  corpuscles  of  the  newly  born  than  in  those  of  older  children  or 
adults,  and  microcytes  are  more  numerous ;  the  oscillations  in  the  number 
of  red  cells  within  twenty-four  hours  are  also  much  more  marked  than  in 
adults. 

H^MATOBLASTS. — Heeiuatoblasts  or  nucleated  red  corpuscles  are  nor- 
mally present  in  the  foetal  blood  and  diminish  in  number  towards  the  end 
of  pregnancy.  They  also  occur  in  the  blood  of  premature  infants,  and 
are  present  in  small  numbers  in  the  blood  of  normal  infants  for  a  few 
days  after  birth  and  then  disappear.  Pathologically  their  presence  may  be 
of  considerable  importance,  and  the  younger  the  child  the  less  intense 
need  the  anaemia  be  which  will  cause  their  appearance  in  the  blood. 

Leucocytes. — The  leucocytes,  or  white  corpuscles,  are  more  numerous 
at  birth  than  in  adults  and  in  young  children.  In  the  first  twenty-four 
hours  the  number  varies  from  18,000  to  30,000  (Schiff,  Gundobin, 
Hayem).  This  is  rapidly  reduced  at  the  end  often  days  to  from  14,000  to 
10,000.  The  daily  variations  in  the  early  days  of  life  are  more  marked 
than  in  adults,  and  the  leucocytosis  of  digestion  is  relatively  higher.  The 
average  number  of  leucocytes  in  an  infant's  blood  after  the  first  two  or 
three  weeks  and  up  to  six  months  is  from  12,000  to  14,000,  and  from  six 
months  to  one  year  from  10,000  to  12,000.  Denis  places  the  number 
of  white  cells  from  the  second  to  the  sixth  year  at  from  9000  to  10,000, 
and  Karnizki  at  12,638.  Bouchut  and  Debrisay  found  the  average  number 
of  counts  in  children  from  two  to  fifteen  years  of  age  to  be  6700. 

Five  varieties  of  white  corpuscles  are  found  normally  in  human  blood, 
and  these  are  classified  as  follows  by  Ehrlich  : 


THE   BLOOD    IX   INFANCY   AND    CHILDHOOD. 


883 


1.  Lymphocytes  (Plate  XV.,  facing  page  884). — These  are  about  the 
size  of  a  red  corpuscle,  and  contain  one  lai^e,  round,  deeply  staining 
nucleus  which  entirely  fills  the  cells.  The  protoplasm  is  not  granular 
and  stains  faintly  or  not  at  all. 

2.  Large  Mononuclear  (Plate  XV.). — These  cells  are  much  larger  than 
the  lymphocytes.  They  have  one  large  oval  nucleus  with  a  broad  margin 
of  non-granular,  almost  colorless  protoplasm  about  it. 

3.  Transitional  (Plate  XV.). — These  cells  are  derived  from  the  last 


CHAET  32. 

SHOWING  APPRO>:iWIATELY  THE  RELATIVE  PROPORTIONS  OFTHE  LEUCOCYTES 

FROM   BIRTH  TO   SIX  YEARS. 

(ADAPTED  FROM  CHARTS  BY  CARSTANJe'n.J 


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884  PEDIATRICS. 

form  and  are  similar  in  size  and  color.     The  nucleus  is  indented  on  one 
side  as  the  result  of  the  beginning  of  nuclear  division. 

These  three  varieties  are  sometimes  called  basophiles.     (Hew^es.) 

4.  Polynudear  Neutrophiles  (Plate  XV.). — These  are  round  cells, 
smaller  than  the  large  mononuclear,  having  a  peculiar  polymorphous 
deeply  staining  nucleus.  The  nucleus  is  long,  irregular  or  twisted,  and 
when  stained  often  appears  segmented.  The  protoplasm  contains  fme 
granules  which  are  stained  by  neutral  stains. 

5.  Polynudear  Eosinophiles  (Plate  XV.). — These  cells  are  usually  about 
the  size  of  neutrophiles  and  have  a  deeply  stained  polymorphous  nucleus. 
The  protoplasm  contains  granules  which  are  much  coarser  than  those  of 
the  neutrophilic  cells,  and  wliich  stain  readily  with  acid  stains. 

These  cells  are  sometimes  called  oxyphiles.     (Hewes.) 

6.  Myelocytes  (Plate  XV.). — These  are  round  or  ovoid  cells  with  one, 
rarely  two,  large  round  or  slightly  bent  nuclei  which  stain  light  blue. 
There  are  two  varieties,  neutrophilic  and  eosinophilic.  The  first  has  a 
protoplasm  crowded  with  fine  neutrophilic  granules.  The  second  con- 
tains coarse  eosinophilic  granules.  Myelocytes  rarely  appear  in  normal 
blood,  but  are  much  increased  in  some  of  the  pathological  states. 

7.  Mast-Cells. — These  are  coarse,  granular  basophiles,  usually  with  a 
trilobar  nucleus.  The  protoplasm  with  Wright's  stain  is  nearly  unstained, 
with  a  number  of  round  white  spots  against  a  faintly  stained  background, 
representing  the  basophilic  granulations. 

Percentages  of  Various  Leucocytes  in  Normal  Blood. — The  varia- 
tions in  the  percentages  of  the  different  kinds  of  leucocytes  in  the  blood 
of  infants  and  young  children,  according  to  the  age  of  the  child,  is  most 
clearly  demonstrated  by  means  of  the  chart  on  the  preceding  page  (883). 

It  will  be  seen  from  the  above  chart  and  from  the  figures  giving  the 
total  leucocytosis  at  birth  and  in  the  subsequent  periods  of  childhood, 
that  in  the  first  day  of  life  polynudear  leucocytosis  exists  which  declines 
rapidly  during  the  next  nine  days,  and  then  very  gradually  until  the  sixth 
month,  when  it  begins  to  mount,  and  at  the  end  of  the  sixth  year  has 
almost  reached  the  adult  level.  The  lymphocytes,  or  small  mononuclear 
leucocytes,  are,  on  the  other  hand,  at  their  minimum  at  birth,  and  in  the 
subsequent  ten  days  increase  with  about  the  same  rapidity  as  the  poly- 
nuclears  decline  in  numbers.  They  reach  their  maximum  about  the  sixth 
month  and  then  gradually  decline  to  the  sixth  year,  while  the  polynuclears 
are  proportionately  increasing.  The  chart  also  show^s  clearly  that  the 
lymphocytosis  so  characteristic  of  the  early  months  of  life  is  almost  wholly 
dependent  upon  an  increase  in  the  lymphocytes  or  small  mononuclear 
cells,  the  large  mononuclear  and  transitional  leucocytes  being  but  little 
changed.  The  eosinophiles  show  a  count  somewhat  higher  than  in  adults^ 
ranging  from  two  to  six  or  even  eight  per  cent.  Their  presence  in  such 
proportions  in  early  childhood  is,  therefore,  of  less  significance  than  in 
later  life. 


PLATE   XV. 


Culex. 
(Resting  Position.) 


Anopheles. 
(Resting  Position.) 


-i-S  ,o 


«  • 


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1 

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Plasmodium  Malarite 

Oil  Immers.  Reichert  ^~. 

\ 

Ocular  No.  3. 

\ 

# 


^.^    t 


Leitz  oil  Immers.  J,.  Ocular  Xo. 


1.  Normal  Red  Corpuscles. 

2.  Ha?matoblasts  or  Nucleated  Red 

Corpuscles : 

a.  Normoblasts. 

b.  Megalobla-sts. 

3.  ilicrocytes. 
■i.  PoikUoeytes. 

■5.  Lymphocytes    or    Small    Mono- 
nuclear. 

6.  Large  Mononuclear : 
a.  Transitional. 

7.  Polynuclear  Neutrophiles. 

8.  Polynuclear  Eosiuophiles : 
a.  Dwarf  Eosinophile. 

9.  Myelocytes: 

a.  Neutrophilic. 

b.  Eosinophilic. 


THE   BLOOD   H   INFANCY  A.\D   CHILDHOOD.  885 

'w  irh  t  fh    f  ?'f  ''"■     "  ''  "''""™'  ""'^  'he  large  mononuclear  cell, 
«hich  IS  the  first  to  appear  in  the  fetal  blood.     According  to  Wolff  the 

rSel?  "™"  blood-corpuscles  may  be  represented  by  the  follow- 


Lymphoid  cell. 


Small  lymphocyte.  Erythrocyte.  j 

Large  lymphocyte.  ,   ,  Myelocyte. 

'  {a)  Basophile. 

{h)  Xeutrophile. 

Polynuclear  leucocytes, 
(a)    With  basophile  granules. 
{b)  With  neutrophile  granules. 

In  the  development  of  the  foetus   the  blood-forming  organs  assume 
certam   speciahzmg  functions.      From   the  lymphoid  cells  of  the  bone 
marrow  the  granular  leucocytes  are  produced,  while  non-granular  cells  or 
lymphocytes  have  their  origin  in  the  lymphoid  tissues,  such  as  the  tonsils 
lymph-nodes,  and  spleen.     If,  however,  either  tvpe  of  cell  is  demanded  by 
the  system  in  excess  of  the  capacity  of  its  own  special  manufacturing 
organ,  the  organ  of  the  other  type  of  cell  may  assume  a  vicarious  function 
and  produce  the  kind  of  ceU'which  is  most  needed.     In  other  word«  the 
bone-marrow  may  produce   lymphocytes   and  the   lymphoid  tissue'  the 
granular  forms  of  leucocytes.     The  greater  proportion  of  lymphocytes  in 
the  blood  in  the  first  two  years  denotes,  therefore,  greater  activity  of  the 
lymphoid  tissue  at  this  period  of  life.     This  natural  tendency  is  exagger- 
ated in  all  forms  of  disease  in  infancy  and  early  childhood  and  is  mani- 
fested by  an  over-development  of  the  organs  in  which  such  tissue  is  found, 
such  as  the  tonsils,  adenoids,  lymph-nodes,  and  spleen,  which  in  almost 
all  the  blood  affections  of  early  life  are  the  organs  most  liable  to  .become 
the  seat  of  the  disease.     This  is  seen  in  the  frequency  of  hypertrophied 
tonsils  and  adenoids  and  the  occurrence  of  lymphadenoma,  lymphosar- 
coma, and  lymphatic  leukaemia  in  infancy ;   whereas  those  diseases,  in 
which  the  pathological  lesions  are  primarily  in  the  bone-marrow,  such  as 
splenic-myelogenous  leukaemia  and  pernicious  anemia,  are  very  rare  in 
infancy. 

THE  BLOOD  IN  ABNORMAL  OONDinONS. 
It  is  recognized  that  all  the  signs  by  which  sickness  is  shown  in  the 
blood  of  adults  are  exaggerated  in  that  of  children.  Their  blood  is  much 
more  sensitive  to  the  action  of  adverse  influences,  such  as  poor  air,  im- 
proper hygienic  surroundings,  improper  food,  the  inhalation  of  arsenic, 
and  numerous  other  causes,  and  anemia  is  much  more  easily  induced! 


886  /EDIATRICS. 

This  is  especially  noticeable  in  the  impoverishment  of  the  blood  which 
follows  gastro-enteric  disease.  Not  only  is  a  condition  of  anEemia  acquired 
by  these  influences,  but  the  development  of  the  blood  may  be  retarded.  In 
this  class  of  cases  the  blood  of  a  child  three  or  four  years  old  may  show 
no  higher  development  than  that  of  a  healthy  infant  in  the  second  year. 

Again,  the  erythrocytes  under  certain  morbid  conditions  may  revert  to 
an  earlier  type.  The  function  of  the  bone-marrow  in  infancy  is  chiefly 
occupied  in  the  production  of  the  erythrocytes.  As  the  marrow  still  has  at 
birth  many  of  its  foetal  characteristics,  any  strain  put  upon  it  by  disease 
makes  it  much  more  likely  to  revert  to  its  foetal  function,  and,  therefore, 
to  manufacture  and  pour  out  into  the  circulation  the  cells  which  are 
characteristic  of  that  period.  The  presence  of  haematoblasts,  myelocytes 
and  eosinophiles  in  infancy  and  early  childhood  are,  therefore,  of  lesser 
significance  than  in  later  life.  Opinions  differ  as  to  the  time  at  which  the 
haematoblasts  disappear  in  the  normal  blood  of  infants.  According  to 
Stengel  and  White  their  presence  after  the  second  day  is  pathological. 
Karnizki,  on  the  other  hand,  claims  to  have  found  normoblasts,  although 
rarely,  in  the  blood  of  healthy  children  up  to  the  middle  of  the  seventh 
year.  The  presence  of  megaloblasts  after  the  first  day  in  full  term  infants 
is  probably  abnormal. 

One  of  the  most  important  points  to  be  remembered  is  that  a 
physiological  leucocytosis  depending  upon  digestion  is  commonly  met 
with  in  infancy,  and  to  a  much  greater  degree  than  at  a  later  period 
of  life,  so  that  what  would  be  a  normal  leucocytosis  at  different  times 
of  the  day,  in  reference  to  the  food  which  has  been  taken,  must 
always  be  borne  in  mind.  It  is  therefore  evident  that  when  we  are 
considering  the  blood  of  an  infant  or  young  child  in  any  given  disease 
we  should  take  into  consideration  what  the  conditions  of  the  blood 
usually  show  in  the  individual, — namely,  as  to  whether  a  normal  con- 
dition, according  to  the  age,  was  present  before  the  onset  of  the  dis- 
ease, or  whether  the  especial  individual  had  already  an  abnormal  blood 
from  backward  development  or  from  some  inherited  or  congenital 
condition.  Enlargement  of  the  spleen  in  infants  is  not  so  significant  as 
in  adult  life,  for  whenever  angemia  is  present  there  is  apt  to  be  an  asso- 
ciated enlarged  spleen. 

A  classification  of  diseases  of  the  blood  is  as  difficult  to  make  and  as 
unsatisfactory  as  that  of  infectious  and  non-infectious  diseases.  It  is 
probable  that  all  the  anaemic  conditions  of  the  blood  will  in  the  future 
be  proved  to  be  secondary,  but  when  the  causes  of  the  pathological  con- 
ditions found  in  the  blood  are  difficult  to  find,  or  apparently  are  insuffi- 
cient to  cause  so  severe  a  disease  as  is  present,  we  speak  of  primary 
anaemia,  while  we  speak  of  secondary  anaemias  as  those  which  have  some 
obvious  cause,  such  as  rhachitis,  malaria,  syphilis,  hemorrhage,  or  any 
debilitating  disease  which  causes  a  reduction  in  the  normal  constituents  of 
the  blood. 


THE   BLOOD   IN   INFANCY  AND   CHILDHOOD.  887 

Specific  Gravity.— In  various  pathological  conditions  the  specific 
gravity  of  the  blood  maj^  be  increased  or  diminished.  Its  changes  usually- 
run  parallel  with  those  in  the  amount  of  haemoglobin,  on  which,  in  fact, 
it  is  largely  dependent.  It  is  diminished  in  all  forms  of  primary  and 
secondary  anaemias,  being  most  diminished  in  leukaemia  and  pernicious 
anaemia  (1028).  It  is  usually  diminished  in  nephritis  (1040)  as  a  result  of 
the  small  amount  of  albuminous  substance  in  the  serum.  It  is  sometimes 
increased  in  cardiac  affections,  and  especially  in  tubercular  meningitis. 

HEMOGLOBIN. — In  children  the  variation  in  the  amount  of  haemoglobin 
present  from  day  to  day  is  more  marked  than  in  adults,  boys  usually 
having  more  haemoglobin  than  girls.  It  is  diminished  in  secondary 
anaemia  and  in  chlorosis,  and  lowest  in  leukaemia  and  pernicious  anaemia 
(15  to  20  per  cent.). 

Red  Corpuscles  [erythrocytes). — A  diminution  in  the  number  of  red 
corpuscles  is  found  in  a  large  number  of  acute  and  chronic  diseases, 
especially  m  those  accompanied  by  a  marked  angemia.  Instances  of  these 
diseases  are  rhachitis,  syphilis,  tuberculosis,  malaria,  and  intestinal  infec- 
tions. In  leuksemia,  and  especially  in  pernicious  anemia,  the  number 
may  fall  to  500,000  per  cubic  centimetre.  Certain  drugs,  such  as  arsenic, 
may  in  poisonous  doses  cause  a  marked  diminution  in  the  number  of  red 
cells.  In  recovery  from  acute  anaemia  the  red  cells  regain  their  normal 
number  much  more  rapidly  than  they  do  their  haemoglobin.  The  red 
corpuscle,  which  normally  has  a  size  of  from  six-  to  nine-thousandths  of 
a  millimetre,  may  undergo  changes  in  size  or  shape,  and  cells  much 
smaller  (microcytes)  or  larger  (macrocytes)  than  the  normal  red  corpuscles 
may  appear,  also  cells  having  oval,  pointed,  or  irregular  forms  (poikilo- 
cytes).  We  have  already  spoken  of  the  fact  that  nucleated  red  corpuscles 
are  found  normally  in  the  blood  of  young  infants.  They  also  readily  ap- 
pear in  quite  large  numbers  in  anaemia.  There  is,  however,  an  essential 
difference  in  their  significance  in  adults  and  in  young  children.  In  the 
former  they  only  appear  at  a  late  period  in  severe  angemia,  and  therefore 
have  a  grave  significance,  while  in  children  they  readily  appear  in  the 
blood  in  simple  anaemias  which  go  on  to  recovery. 

White  Corpuscles  (leucocytes). — The  white  corpuscles  are  affected  in 
a  temporary  or  permanent  manner  by  many  physical  and  pathological 
conditions  in  the  body  at  large  as  well  as  in  the  blood-forming  organs. 
The  most  common  change  from  the  normal  is  that  of  leucocytosis.  Leu- 
cocytosis  was  originally  described  by  Ehrlich  as  the  presence  in  the  blood 
of  a  greater  number  of  white  cells  than  normal  for  the  individual,  or  a 
relatively  increased  number  of  any  variety  of  white  cells,  with  or  without 
an  increase  in  the  total  number  of  leucocytes.  Cabot  has  restricted  the 
term  leucocytosis  to  an  increase  of  leucocytes  in  which  the  polynuclear 
cells  predominate,  and  uses  the  terms  lymphocytosis  and  eosinophilia  to 
describe  a  relative  increase  of  the  lymphocytes  and  cosinophiles.  Physio- 
logically, we  find  a  leucocytosis  after  the  ingestion  of  any  proteid  food. 


888  PEDIATRICS. 

It  is  at  its  height  about  two  hours  after  a  meal,  when  the  total  number 
of  leucocytes  may  be  as  great  as  from  13,000  to  30,000,  accordmg  to 
the  age  cf  the  child.  Pathologically,  a  leucocytosis  follows  a  consider- 
able number  cf  diseases,  and  seems  in  a  general  way  to  depend  upon  the 
amount  of  local  reaction  to  which  the  disease  gives  rise.  We  find  a 
pronounced  leucocytosis  in  most  fevers  and  in  most  septic  processes.  In 
these  cases  the  increase  i3  almost  wholly  composed  cf  the  poiynuclear  neu- 
trophiics,  wiiich  may  make  up  from  90  to  98  per  cent,  cf  the  entire  leuco- 
cyte comit.  The  leucocytosis  does  not  depend  on  the  degree  of  fever, 
does  not  always  occur  with  it,  and  conversely  inflammatory  leucocytosis 
may  appear  before  the  fever.  Pneumonia  shows  generally  a  leucocytosis. 
In  pneumonia  the  large  mcrease  in  the  number  of  leucocytes  seems  to 
follow  closely  the  course  of  the  pathological  process,  and  the  "blood 
crisis*'  is  found  to  anticipate  the  "temperature  crisis"  by  some  hours. 
Pericarditis  and  endocarditis,  advanced  pulmonar\'  phthisis,  pleuritis, 
erysipelas,  acute  rheumatism,  purulent  meningitis,  pharyngitis,  diphtheria, 
septicsemia,  osteomyelitis,  scarlet  fever,  variola,  tonsillitis,  bronchitis, 
peritonitis,  acute  nephritis,  certain  gastro-enteric  infections,  measles,  in  the 
prodromal  stage,  rhachitis  (especially  basophiles),  some  profound  anaemias, 
Avhether  primary  or  secondary,  leukaemia,  hemorrhage,  malignant  new 
growths,  abscess  of  any  kind,  including  appendicitis,  and  many  skin  dis- 
eases are  among  the  affections  that  show  leucocytosis.  In  leukeemia  the 
leucocytes  are  increased  more  than  in  any  other  disease,  they  may  reach 
500,000  per  cubic  millimetre;  and  the  proportion  of  the  white  to  the  red 
corpuscles  may  be  1  to  20  or  even  1  to  6.  Certain  drugs  cause  leuco- 
cytosis, such  as  pilocarpine,  antipyrin,  thyroid  extract,  and  tuberculin. 

The  diseases  in  which  the  leucocytes  are  approximately  normal  are 
malaria,  measles,  after  the  appearance  of  the  efflorescence,  serous  perito- 
nitis, influenza,  typhoid  fever,  pulmonary  tuberculosis  (unless  there  is  a  sec- 
_  ondary  infection  by  other  bacteria),  rubella,  mumps,  and  most  cases  of 
epidemic  influenza.  In  tubercular  meningitis  and  peritonitis,  leucocytosis 
may  or  may  not  be  present.  Comparing  these  two  lists  it  will  be  seen 
that  there  are  instances  in  wliich  the  leucocyte  count  may  be  of  great 
importance  to  the  physician  in  making  a  differential  diagnosis. 

The  significance  of  the  iodine  reaction  in  children  has  been  studied  by 
Dunn.     He  summarizes  his  results  as  follows  : 

1.  The  reaction  is  always  present,  usually  of  average  and  often  of 
marked  intensity,  a  high  percentage  of  cells  being  affected  in  the  following 
conditions :  Lobar  pneumonia,  broncho-pneumonia,  cerebrospinal  men- 
ingitis, epidemic  influenza,  empyema,  suppuration  (non-tubercular),  and 
was  found  present  in  single  cases  of  appendicitis,  diphtheria  and  starva- 
tion. 

2.  The  reaction  is  usually  present  but  may  be  absent  in  cases  of 
typhoid  fever,  and  miliary  tuberculosis. 

3.  The  reaction  may  be  absent  or  present  in  anaemia. 


THE   BLOOD   IN   INFANCY  AND   CHILDHOOD.  889 

4.  The  reaction  is  usually  absent  but  may  be  present  in  nephritis, 
cardiac  valvular  disease  and  tuberculosis. 

5.  The  reaction  is  absent  in  pleurisy  with  effusion,  functional  indiges- 
tion, rhachilis,  rheumatic  fever,  congenital  cardiac  disease,  chorea,  infan- 
tile atrophy  and  was  found  absent  in  single  cases  of  bronchitis,  eczema, 
purpura,  urticaria  and  scorbutus. 

LEUK^MLA.. 

The  disease  called  leukaemia  sometimes  occurs  in  infancy  and  child- 
hood. Klebs,  von  Jaksch,  and  Sanger  describe  congenital  cases.  On  the 
whole,  it  is  a  rare  disease  in  infancy,  and  when  it  occurs  it  is  generally  of 
the  lymphatic  variety.  A  pure  myelogenous  form  of  leukaemia  is  very  rare. 
Hutchison  could  find  but  five  undoubted  cases  in  medical  literature,  and 
only  one  of  these  was  in  an  infant.  These  did  not  include  Morse's  case, 
which  occurred  in  an  infant  of  one  year.  The  etiology  of  the  disease  is 
obscure.  Cases  have  been  reported  which  followed  congenital  syphilis 
and  rhachitis.  It  is  thought  by  some  to  be  an  infectious  disease,  but  the 
evidence  is  insufficient.  Von  Limbeck  thinks  that  it  is  a  disease  of  the 
lymphatic  system.  Others  say  that  any  anaemia  or  Ilodgkin's  disease  may 
progress  to  leukaemia  under  certain  circumstances,  as  may  also  anaemia 
infantum  pseudo-leukaemica.  A  number  of  the  cases  are  apparently 
primary.  Males  are  more  prone  to  the  disease  than  females.  The  essen- 
tial feature  is  a  persistent  increase  in  the  number  of  the  white  corpuscles 
of  the  blood,  associated  with  changes  in  the  spleen,  lymph-glands,  or 
bone-marrow. 

Pathological  Anatomy. — Leukaemia  is  a  rare  affection  in  infancy  and 
childhood,  and  the  recorded  observations  of  these  cases  in  early  life  are 
very  incomplete.  In  the  splenie  myelogenous  form  the  spleen  is  much 
enlarged.  The  condition  of  the  organ  is  one  of  chronic  hyperplasia,  often 
with  grayish-white  lymphoid  tumors  scattered  through  it.  The  essential 
change  in  the  bone-marrow  is  a  great  hyperplasia  of  the  red  marrow, 
which  contains  large  numbers  of  nucleated  red  corpuscles  in  all  stages  of 
development,  also  myelocytes  and  other  cells.  In  the  lymphatic  form  of 
the  disease  there  is  a  general  enlargement  of  the  lymphatic  glands  and 
other  lymphoid  tissues  as  a  result  of  simple  hyperplasia.  This  is  usually 
associated  with  a  moderate  enlargement  of  the  spleen.  The  liver,  as  a 
rule,  is  considerably  enlarged  in  both  forms  of  leukaemia. 

Leukaemia  is  one  of  the  few  diseases  which  can  be  diagnosticated 
definitely  from  the  blood  examination  alone.  There  is  a  more  or  less 
marked  diminution  in  the  number  of  the  red  corpuscles,  the  blood  count 
ranging  from  2,000,000  to  4,000,000,  except  in  the  early  stages,  with 
some  irregularities  in  the  size  and  shape  of  the  corpuscles.  The  h^emo- 
globin  is  usually  much  diminished.  The  uTiportant  change  is  in  the  leu- 
cocytes, which  are  enormously  increased  in  number,  the  proportion  being 
frequently  1  to  15  of  the  red,  and  sometimes  even  1  to  3.     In  the  splenic 


890  PEDIATRICS. 

myelogenous  form  the  chief  point  of  interest  is  the  great  increase  ni  the 
number  of  myelocytes,  which  average  about  35  per  cent,  of  the  white 
corpuscles,  and  may  be  even  60  per  cent.  The  eosinophiles  are  some- 
times relatively  increased.  The  percentage  of  polynuclear  neutrophiles  is 
usually  diminished,  and  the  lymiDnocytes  show  a  great  relative  diminu- 
tion. Many  nucleated  red  cells  are  present.  In  the  lymphatic  form  the 
character  of  the  blood  is  materially  different,  and  the  increase  in  the 
number  of  leucocytes  is  not  usually  so  great.  The  increase  is  due  solely 
to  the  lymphocytes,  all  the  other  forms  being  greatly  diminished  rela- 
tively. In  the  acute  forms  the  large  lymphocytes  are  predominant ;  in  the 
chronic  forms  the  small  lymphocytes  make  up  the  bulk  of  the  leucocytes. 
Eosinophiles  and  nucleated  red  cells  are  rare.  Myelocytes  are  not  present 
or  are  rare.  Tliis  description  of  the  blood  applies  to  children  as  well  as  to 
adults,  but  there  are  practically  no  complete  data  as  to  the  character  of 
the  blood  of  leukgemias  in  infancy. 

Symptoms. — The  onset  is  usually  insidious,  and  the  first  striking  signs  are 
pallor,  progressive  enlargement  of  the  abdomen,  enlarged  glands,  shortness 
of  breath,  general  weakness  and  hemorrhages  from  the  mucous  mem- 
branes. The  progress  of  the  disease  is  usually  much  more  rapid  in  chil- 
dren than  in  adults.  The  symptoms  are  sunilar  in  the  two  types  of  the 
disease.  The  lymphatic  form  of  the  disease  is  more  common  than  the 
splenic  myelogenous  in  infants  and  children.  The  child  becomes  gradually 
l^ale  and  weak,  and  suffers  from  dyspepsia  and  repeated  diarrhoea.  The 
respirations  are  accelerated,  and  dyspnoea  is  shown  on  slight  exertion. 
Fainting  attacks  may  occur.  Hemorrhage  from  the  nose  is  common,  and 
may  occur  from  the  stomach,  intestine,  or  kidneys,  or  into  the  skm.  The 
pulse  is  usually  rapid  and  soft.  There  are  rarely  any  cardiac  symptoms. 
Headache  and  vertigo  are  marked  at  times.  Vision  may  be  much  im- 
paired as  the  result  of  retinal  hemorrhages  or  leuksemic  plaques.  Tender- 
ness over  the  shafts  of  the  long  bones  has  been  occasionally  observed. 
The  urine  presents  no  constant  changes.  It  occasionally  contains  albumin 
and  casts.  A  moderate  degree  of  fever  is  usually  present  in  the  late 
stages,  also  oedema  of  the  feet  and  general  anasarca. 

In  the  mixed  forms  of  leukaemia  we  find  characteristic  blood  changes 
which  cannot  be  wholly  classed  as  "  myelogenous  "  or  "  lymphatic.''  They 
are  also  intermediate  between  the  anaemia  mfantum  iDseudo-leuktemica 
(splenic  anaemia  of  infants)  and  leukcemia.  Hutchison  attempts  to  explain 
the  origin  of  these  mixed  forms  by  accepting  Wolff'' s  theory  of  the  deriva- 
tion of  the  leucocytes  (see  page  885),  and  so  regarding  the  myelocytes  and 
lymphocytes  as  both  arising  from  a  common  parent  type  of  cell,  the 
lymphoid  cell.  He  considers  myelogenous  leukaemia  as  being  due  to  the 
production  from  this  parent  lymphoid  cell  of  an  excess  of  myelocytes ; 
the  lymphatic  leukaemia,  to  an  excess  of  lymphocytes ;  and  the  mixed 
forms  either  to  the  parent  cells  themselves  entering  the  blood  along  mth 
the  myelocytes,  or  to  an  excessive  production  of  both  myelocytes  and 


THE   BLOOD    IN   INFANCY   AND    CHILDHOOD.  891 

lymphocytes  from  the  common  parent  ceh.  There  is  some  evidence  to 
believe  that  both  blood  manufacturing  organs,  the  marrow  and  lymph 
apparatus,  may  have  a  vicarious  function,  and  so  on  occasions  produce 
either  type  cf  ceh,  the  myelocyte  or  lymphocyte.  He  sug^asts  that  the 
rarity  of  myelogenous  leukaemia  in  early  childhood  may  be  due,  as  in  the 
case  of  pernicious  anaemia,  to  the  fact  that  the  cause  of  the  disease  is  not 
operative  at  this  early  age. 

The  follov^ing  table  shows  the  average  percentages  of  the  different  ele- 
ments of  the  blood  in  the  splenic  myelogenous  and  lymphatic  leukaemias : 

TABLE   71. 

Average  Percentages  of  the  Different  Elements  of  the  Blood  in  the  Splenic  Myelogenous  and 

Lymphatic  Leukcemias. 

Splenic  Myelogenous  Lymphatic  Leu- 

LeulicEinia.  kaemia. 

Hemoglobin 25  to  50  per  cent.  25  to  40  per  cent. 

Ked  corpuscles 2,000,000  to  3,000,000         2,000,000  to  3,000,000 

"White  corpuscles 100,000  to  400,000  60,000  to  100,000 

Lymphocytes 10  per  cent.  96  per  cent. 

Poly  nuclear  leucocytes 50       "  3       n     '         ' 

Eosinophiles 5       "  rare. 

Myelocytes 35       "  usually  absent. 

Nucleated  reds very  numerous.  rare. 

Diagnosis. — ^A  distinction  is  chiefly  to  be  made  between  leukemia 
and  Hodgkin's  disease,  or  secondary  anaemia  with  leucocytosis,  which 
in  infancy  is  often  accompanied  by  an  enlarged  spleen.  The  difference 
between  leukaemia  and  pseudo-leukaemia,  is  explained  on  page  898. 

The  differential  diagnosis  of  leukemia  is  impossible  by  means  of  the 
clinical  history,  and  can  be  made  only  by  examination  of  the  blood.  The 
increase  in  the  number  of  leucocytes  is  far  greater,  as  a  rule,  in  leukaemia 
than  in  other  conditions,  but  the  characteristic  feature  in  the  splenic 
myelogenous  form  is  the  presence  of  abnormal  cells,  namely,  the  myelo- 
cytes, and  in  the  lymphatic  form  a  great  absolute  and  relative  increase  of 
the  mononuclear  cells.  In  Hodgkin's  disease  and  in  the  secondary  anae- 
mias with  leucocytosis  there  is  a  simple  increase  of  the  normal  forms  of 
leucocytes.  In  some  cases  of  Hodgkin's  disease  also  the  blood  may  be 
normal.  Chronic  adenitis,  which  might  be  confounded  with  lymphatic 
leukaemia,  shows  usually  normal  blood,  and  is  thus  readily  differentiated. 
In  distinguishing  between  the  two  forms  of  leukaemia  we  rely  much  more 
on  the  quality  of  the  blood  than  on  the  other  clinical  characteristics. 

Prognosis. — The  course  is  chronic  and  usually  progressive,  although 
recovery  occasionally  occurs.  The  great  majority  of  cases  prove  fatal 
within  a  few  months,  although  occasionally  cases  have  been  reported  of 
three  to  five  years'  duration.  Epstein  and  others  have  described  an  acute 
form  with  a  rapid  course  of  a  few  days  or  weeks.  High  fever,  frequent 
hemorrhages,  and  marked  oedema  are  unfavorable  symptoms.  The  lym- 
phatic cases  run  a  shorter  course  and  are  more  uniformly  fatal  than  those 
of  the  splenic  myelogenous  type. 


892  PEDIATRICS. 

Treatment. — As  in  all  cases  of  ansemia,  fresh  air  and  careful  feeding 
are  important  indications.  We  have  no  specific  for  the  disease,  and  the 
results  of  treatment  by  drugs  of  any  kind  are  discouraging,  although  an 
occasional  rare  recovery  has  been  reported.  Arsenic,  in  the  form  of 
Fowler's  solution,  given  in  large  doses,  has  proved  the  most  efficient 
remedy.  Iron  is  also  of  some  value.  The  most  useful  preparations  are 
ovoferrin,  peptomangan,  ferratin,  saccharated  oxide,  and  the  tartrate 
of  iron  and  potassium.  Organotherapy  has  been  used  lately  with  some 
success.  Bigger,  de  Feodosia,  and  "Whait  reported  cases  of  rapid  im- 
provement after  giving  bone-marrow  by  the  moutli.  A  glycerin  extract  of 
the  spleen  has  been  tried  with  little  success.  The  results  of  splenectomy 
thus  far  indicate  that  it  is  not  a  desirable  measure. 

The  following  case  of  acute  lymphatic  leukeemia  occurred  in  the  prac- 
tice of  Dr.  ^lorse : 

The  child,  a  girl,  was  three  years  old  and  was  healthy  at  birth.  Her  mother  had 
died  of  pneumonia  when  she  was  two  years  old.  Her  father  was  well.  There  was  no 
tubercular  or  syphilitic  history.  She  was  nursed  for  a  year  and  then  fed  from  the 
table.  She  was  always  subject  to  diarrhoea,  but  otherwise  had  been  well.  No  history 
could  be  obtained  except  that  six  days  previous  to  being  seen  blood-spots  had  appeared 
on  the  skin  and  the  mouth  had  become  sore.  She  had  also  A'^omited  blood  and  had 
passed  some  blood  from  the  bowels. 

She  looked  seriously  sick  and  was  very  pale,  but  was  fairly  developed  and  was  not 
especially  thin.  Her  gums  were  swollen,  spongy,  and  bleeding,  her  tonsils  were  large, 
and  her  throat  was  reddened.  There  was  a  systolic  murmur  over  the  precordia.  The 
lungs  were  normal.  The  abdomen  was  lax.  The  edge  of  the  liver  was  felt  about  one 
inch  below  the  costal  border.  The  spleen  was  palpable  below  the  border  of  the  ribs 
to  the  extent  of  three  inches  in  breadth  and  two  inches  in  length.  There  was  slight 
glandular  enlargement.  There  were  numerous  petechite  over  the  legs  and  abdomen. 
There  were  no  evidences  of  rhachitis,  no  tenderness  about  the  joints,  nor  swelling  over 
the  long  bones.     The  temperature  was  normal.     The  blood  count  was  as  follows  : 

Haemoglobin 25  per  cent. 

~       Ked  corpuscles 2,024.000 

White  corpuscles   87.400 

Lymphocytes 83  per  cent. 

Large  mononuclear  cells 11         " 

Polynuclear  neutrophiles 5         " 

Eosinophiles 1         " 

There  was  a  slight  variation  in  the  size  of  the  red  corpuscles,  almost  none  in  shape. 
There  were  no  nucleated  forms,  and  no  myelocytes. 

A  fresh  liquid  diet,  lemon-juice,  and  stimulants  were  ordered.  The  bleeding 
from  the  gums  and  bloody  discharges  continued,  as  did  the  purpuric  efflorescence. 
The  child  was  not  seen  again,  but  died  a  week  later.     There  was  no  autopsy. 

In  the  light  of  the  above  history  and  blood  examination  there  can  be  no  doubt  as 
to  the  correctness  of  the  diagnosis  of  acute  lymphatic  leukaemia.  If  the  history  can 
be  accepted  as  correct,  the  onset  was  acute,  there  were  subcutaneous  hemorrhages  and 
bleeding  from  the  gums,  and  the  duration  of  the  disease  was  only  two  weeks.  Owing 
to  the  circumstances  of  the  child's  surroundings,  however,  it  is  possible  that  these 
marked  symptoms  may  have  been  preceded  for  a  time  by  others  less  noticeable.  The 
■  duration  of  the  disease  could  not  have  been  more  than  seven  weeks.  Although  the 
glandular  enlargement  was  not  marked,  that  of  the  spleen  was   considerable.     The 


THE    BLOOD    IX    INFANCY   AND    CHILDHOOD.  893 

great  bulk  of  the  white  corpuscles  was  made  up  of  lymphocytes.     The  large  mono- 
nuclear forms  were  also  somewhat  increased  in  number. 

The  following  case  of  splenic  myelogenous  leukaemia  also  came  under 
the  observation  of  Morse  at  the  Infants'  Hospital : 

-  A  boy,  one  year  old,  came  to  the  out-patient  department  on  April  26.  His 
parents  were  Russians,  and  seemed  well  and  strong.  No  history  of  syphilis  or  tuber- 
culosis could  be  obtained.  Four  other  children  were  alive  and  well,  two  had  died  of 
some  acute  disease  in  Russia.  No  very  definite  history  of  his  illness  could  be  obtained. 
He  was  weaned  at  three  months  and  had  been  fed  exclusively  on  condensed  milk  for 
six  months.  He  had  been  failing  gradually  for  some  months.  His  abdomen  had  been 
large  for  two  months,  and  he  had  been  unable  to  lie  on  his  left  side  for  one  month.  He 
had  never  had  epistaxis  or  henaorrhages  from  the  stomach  or  bowels.  He  had  never 
had  any  eruption  on  the  body.  He  vomited  occasionally.  His  bowels  were  somewhat 
constipated,  and  the  dejections  were  light-colored. 

The  infant  was  markedly  atrophic  and  anaemic.  The  head  was  large,  the  forehead 
prominent,  and  the  anterior  fontanelle  widely  open.  There  was  a  moderate  rosary  and 
an  enlargement  of  the  epiphyses,  with  slight  bow- legs.  There  was  marked  enlarge- 
ment of  the  glands  of  the  neck,  axillae,  and  groins.  The  heart  and  lungs  were  normal. 
The  abdomen  w^as  very  much  enlarged,  but  contained  no  fluid.  The  superficial  veins 
w^ere  distended.  The  dulness  of  the  liver  began  at  the  upper  border  of  the  fifth  rib 
in  the  mammillary  line,  and  the  lower  border  could  be  felt  round  and  smooth  about 
two  fingers'  bread'h  below  the  costal  border  in  the  same  line.  The  spleen  was  very 
much  enlarged.  It  could  be  felt  beneath  the  costal  margin  just  outside  the  parasternal 
line,  and  just  outside  the  umbilicus  ;  it  then  extended  beyond  the  middle  line,  and 
filled  up  almost  the  whole  left  iliac  region.  The  notch  could  be  plainly  felt.  The 
spleen  and  abdomen  w^ere  not  at  all  tender.  There  were  hemorrhagic  spots  on  the  skin. 
The  blood  examination  made  at  this  time  is  given  below. 

It  was  impossible  to  keep  the  child  under  observation,  but  he  was  seen  again  on 
May  28.  He  had  failed  rapidly  during  the  month.  His  skin  was  very  pale  with  a 
decided  yellow  tinge,  the  face,  body,  and  extremities  being  thickly  covered  mth  pur- 
puric spots,  varying  in  size  from  that  of  a  pin's  head  to  that  of  a  lead-pencil.  These  spots 
had  appeared  two  days  before,  at  which  time  he  developed  a  cough,  and  refused  to  eat. 
He  had  no  other  hemorrhages.  The  bowels  were  loose,  the  dejections  were  of  normal 
color,  and  there  was  no  vomiting.  An  examination  of  the  chest  showed  a  broncho- 
pneumonia involving  the  lower  two-thirds  of  the  left  lung,  and  a  well-marked  bron- 
chitis in  the  right  lung.  The  heart  was  normal.  The  abdomen  was  rather  more  dis- 
tended, was  not  tender,  and  there  was  no  fluid.  There  was  a  slight  increase  in  the  size 
of  both  the  liver  and  spleen.     He  was  almost  moribund. 

The  usual  association  of  leukaemia  with  rhachitis  was  present  in  this  case,  the 
leukaemia  having  probably  developed  subsequent  to  the  rhachitis.  The  latter  was  un- 
doubtedly due  to  improper  food  and  surroundings,  and  it  seems  more  reasonable  in  the 
present  state  of  our  knowledge  to  consider  the  leukasmia  as  arising  from  the  same  cause 
rather  than  secondary  to  the  rhachitis.  The  blood  count  made  on  April  26  showed 
2  900,000  red  corpuscles  and  48,000  white  corpuscles  per  cubic  millimetre,  giving  a 
proportion  of  1  to  60. 

The  differential  count  of  one  thousand  white  corpuscles  on  slips  dried  and  stained 
with  Ehrlich's  triple  stain  resulted  as  follows  : 

Small  lymphocytes 23.4  per  cent. 

Large  lymphocytes  and  transitional  forms 8. 1        " 

Myelocytes 21.4 

Polynuclear  neutrophiles 46.5        " 

Eosinophiles . . . ; 6        " 


894  PEDIATRICS. 

A  slip  stained  with  eosin  and  methylene  hlue  showed  numerous  mononuclear  and 
polynuclear  cells  with  fine  granulations  which  took  the  eosinophile  stain  feebly.  A 
slip  stained  with  dahlia  showed  the  presence  of  very  few  "mastzellen."  Numerous 
partially  destroyed  cells,  both  mononuclear  and  polynuclear,  were  found. 

There  was  a  very  marked  poikilocytosis,  a  moderate  number  of  microcytes,  and 
numerous  macrocyles,  many  of  these  being  three  times  the  diameter  of  a  normal  red 
corpuscle.  Many  of  these  forms  lacked  the  normal  concavity.  Nucleated  red  cells 
were  present  in  great  abundance.  No  microblasts  were  seen.  Many  cells  the  size  of 
normal  corpuscles  were  met  with  in  which  the  nucleus  was  smooth,  feebly  stained,  and 
with  little  nuclear  structure,  the  protoplasm  being  not  quite  homogeneous,  "wrinkled," 
and  stained  a  reddish  violet.  These  may  perhaps  be  regarded  as  undeveloped  normo- 
blasts. Normoblasts  were  very  abundant,  and  always  with  one  nucleus,  which  showed 
a  well-developed  nuclear  structure,  and  which  occasionally  presented  indentations  as  if 
division  was  beginning.  The  nucleus  was  rarely  in  the  centre,  often  on  the  side,  some- 
times half-way  out  of  the  cell  and  occasionally  free.  The  protoplasm  was  ordinarily 
narrow,  but  sometimes  wide.  A  few  cells  were  met  with  from  which  the  nucleus  had 
probably  escaped.  Megaloblasts  were  quite  numerous  and  presented  the  same  varia- 
tions as  the  normoblasts.  In  addition  to  these  a  number  of  large  oval  cells  were  seen 
which  contained  two  nuclei,  the  long  diameter  of  the  cells  being  about  four  times  that 
of  the  normal  red  corpuscles.  In  several  of  these  well-marked  karyokinetic  figures 
were  present ;  these  variations  in  the  erythrocytes,  of  course,  merely  showed  a  severe 
grade  of  secondary  anaemia. 

The  following  case  of  lymphatic  leukaemia  occurred  at  the  Children's 
Hospital  in  our  service,  and  has  been  reported  by  Drs.  Morse  and  Low. 
It  illustrates  the  difficulty  that  sometimes  arises  in  the  early  stages  of  the 
disease  in  cliilclren  in  differentiating  between  leukaemia,  pseudo-leukaemia, 
and  malignant  lymphoma,  both  from  an  examination  of  the  blood  and 
of  sections  of  the  affected  glands  : 

Bessie  C,  a  Jewess,  was  admitted  to  the  Children's  Hospital  on  August  23,  1904, 
when  three  and  one-half  years  old.     The  family  history  was  negative. 

Previous  History. — She  was  normal  at  birth,  weighed  nine  and  one-half  pounds, 
_^nd  was  nursed  fifteen  months.  She  had  chicken-pox  at  six  months,  anterior  polio- 
myelitis involving  the  right  arm  and  both  legs  at  eighteen  months,  whooping-cough  at 
two  years,  and  measles  at  two  and  one-half  years.  No  sequete  followed  either  the 
whooping-cough  or  the  measles.  She  had  practically  recovered  from  the  infantile 
paralysis,  except  that  she  used  the  right  arm  less  freely  than  the  left. 

Present  Illness. — Loss  of  weight  and  strength,  which  began  about  the  first  of  June, 
had  progressed  steadily  but  slowly.  There  had  been  an  increasing  pallor  during  the 
same  time.  Her  only  complaints  had  been  of  a  tired  feeling  and  of  pain  in  the  ears. 
Her  appetite  had  been  poor,  and  she  had  had  occasional  attacks  of  abdominal  pain 
followed  by  nausea  and  vomiting.  The  vomitus  contained  mucus  and  food,  with  some 
bile.  There  had  been  a  slight  cough  for  some  weeks.  Puffiness  of  the  face  and  swell- 
ing of  the  neck  had  not  been  noticed  until  two  weeks  before  entrance.  There  had 
been  no  hemorrhages. 

Physical  Examination. — She  was  well  developed  and  nourished  and  perfectly  clear 
mentally.  There  was  marked  pallor  of  the  skin,  with  a  slight  yellowish  tint.  The 
mucous  membranes  were  pale.  There  was  puffiness  about  the  eyes.  There  were 
slightly  diminished  respiratory  movements  of  the  right  chest.  There  was  dulness  on 
the  right  side  below  the  second  rib  continuous  with  the  liver  and  heart  dulness  and 
extending  back  to  the  anterior  axillary  line.  There  was  hyper-resonance  over  the 
remaining  portion   of  the  right  side.     The  respiration  was  diminished  in  intensity 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD. 


895 


in  the  dull  area  and  was  also  broncho-vesicular  in  character.  The  expiration  was 
prolonged.  Fluoroscopic  examination  showed  a  dark  area  corresponding  to  this 
area  of  dulness.  The  left  lung  was  normal  except  for  exaggerated  respiration  and 
an  occasional  sibilant  rale.  Tlie  cardiac  impulse  was  visible  and  palpable  in  the 
fifth  space  in  the  nipple  line.  The  upper  border  of  the  cardiac  dulness  was  in  the 
third  space  and  the  left  in  the  nipple  line  ;  the  right  could  not  be  determined.  The 
action. was  regular,  the  sounds  clear.  The  second  pulmonic  sound  was  decidedly  the 
louder.  The  abdomen  was  full  and  tympanitic.  There  were  no  evidences  of  fluid  or 
of  new  growths.  The  lower  border  of  the  liver  Avas  palpable  4J  cm.  below  the  costal 
border  in  the  nipple  line.     The  spleen  was  just  palpable.     There  was  considerable 


Fig.  185. 


Acute  lymphatic  leuksemia,  in  a  girl  of  33^  years,  showing  enlargement  of  cervical  and  axillary 
lymph-nodes,  and  spleen,  and  slight  enlargement  of  the  liver. 

atrophy  of  the  muscles  of  the  right  forearm,  with  a  weakened  grasp  on  that  side. 
Both  le'^s  were  a  little  weak  and  tlie  muscles  on  the  right  were  flabby.  The  knee-jerks 
were  present,  but  diminished,  on  both  sides.  The  plantar  reflexes  were  normal. 
There  Avas  no  oedema  of  the  dependent  portions.  There  wei'e  firm  swelhngs,  not 
tender,  in  the  region  of  the  parotid  and  sub-maxillary  glands.  There  were  many 
laro-e,  firm,  non-tender  lymph-nodes  varying  in  size  from  that  of  a  pea  to  that  of  a 
laro-e  cherry  in  the  post-cervical,  axillary,  and  inguinal  regions.  The  skin  Avas  not 
adherent  over  these  enlarged  nodes  and  shoAved  no  evidences  of  inflammation.  The 
left  epitrochlear  gland  Avas  the  size  of  a  large  pea  ;  the  right  Avas  not  felt. 

The  urine  was  pale,  acid,  of  a  specific  gravity  of  1.020  and  contained  a  trace  of 
albumin,  but  no  bile  or  sugar.  The  sediment  showed  a  large  amount  of  ammonium 
urate  and  a  feAV  crystals  of  cystin. 


896 


PEDIATRICS. 


The  blood  at  entrance  contained  45  per  cent,  of  hfemoglobin,  2,080,000  red  cor- 
puscles, and  16,200  white  corpuscles.     A  differential  count  was  not  made. 

The  history  of  the  changes  which  took  place  in  the  blood  is  best  shown  in  the  fol- 
lowing table  : 


TABLE  72. 


o 

o 

ri- 

O 
o 

cl- 

* 

o 

o 

CO 

>> 

a1 

te 

to 

Date. 

w 

o 

h- ' 
o 

CO 
o 

05 

CO 
1—1 

CO 

to 

to 

or 

-1 

^J 

t^ 

*- 

o 

Ol 

Oi 

o 

o 

o 

Oi 

Haemoglobin. 

■^ 

s< 

^ 

s^ 

m 

^ 

^ 

to 

to 

*- 

*> 

h- 1 

to 

CD 

to 

to 

00 

-<I 

o 

05 

o 

o 

03 

OS 

o 

Ol 

o 

o 

Ol 

o 

Red  Corpuscles. 

^ 

o 

o 

o 

Q 

o 

o 

o 

o 

o 

f—l 

o 

o 

o 

o 

o 

o 

o 

h-i 

^J 

*^ 

CO 

CO 

to 

1— 1 

h-1 

4^ 

CD 

o 
"bi 

4^ 

"b 

CO 

lo 

CD 

~b 

lo 

Whte  Corpuscles. 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

^ 

>4^ 

Or 

Cft 

or 

bS 

00 

GO 

o 

Oi 

Ol 

o 

Oi 

CD 
1— ' 

o 

o 

b 

Small  Mononuclear. 

■^ 

^ 

"^ 

■^ 

"^ 

■^ 

h-l 

to 

to 

h-l 

1— I 

^J 

00 

to 

Oi 

b 

■■<I 

o 

b 

b 

Large  Mononuclear. 

•^ 

■^ 

^ 

■^ 

"^ 

^ 

to 

1—1 

00 

to 

CO 

C3i 

o 

h*i- 

^2. 

o 

o 

^ 

b 

o 

bo 

bo 

Polynuclear  Jveutrophiles. 

^ 

^ 

^ 

^ 

"^ 

"^ 

•^ 

h- ' 

o 

1— 1 

o 

o 

o 

*^ 

o 

In3 

to 

Eosinophiles. 

s< 

^ 

s^ 

S^ 

s^ 

*" 

to 

l-l 

to 

to 

o 

o 

o 

CJl 

o 

Myelocytes. 

■^ 

^• 

s< 

^ 

^ 

to 

o 

o 

1—1 

o 

to 

o\ 

o 

Mast-Cells. 

^ 

^ 

^ 

^ 

to 

Microblasts. 

1-9 
o 

Ol 

*- 

to 

J5 

05 

]— 1 
CO 

Normoblasts. 

1— ' 
GO 

to 

en 

to 

bO 

to 

Megalobl^sts. 

S 

^ 

d 

CO 

n 
3' 

o 

o 

1^ 

!^ 

o 

o 
a- 

o 

p. 

3 

Polychromatophilia. 

g 

50 

3 
(SQ 
CD 

^ 

o 

o 

9 

o 

P 

o 

3 

3 

Variation  in  size. 

p. 

i 

O 

p- 

a- 

P 

CO 

< 
a 

CO     _ 
O) 

o 

o 

a 

o 
3 

0| 

o 
p- 

Poikilocytosis. 

r/} 

cc 

cr<5 

OQ 

•-o 

Stippling. 

cr 

3* 

rt- 

en- 

Although  the  percentage  of  the  mononuclear  cells,  and  especially  of  the  small 
mononuclear  cells,  was  large  from  the  very  beginning,  it  was  felt  that  when  the  age  of 
the  child  and  the  total  number  of  white  corpuscles  were  taken  into  consideration  that 
the  diagnosis  of  lymphatic  leukaemia  was  not  justified  and  that  search  must  be  carried 
further.     It  seemed  possible  to  exclude  syphilis  by  the  family  history  and  the  absence 


THE   BLOOD   IN   LNFANCY   AND    CHILDHOOD.  897 

of  past  or  present  signs  of  the  disease.  Tuberculosis  was  excluded  because  3  mgms. 
of  tuberculin  caused  no  reaction.  No  parasites  or  eggs  of  parasites  could  be  found  in 
the  dejections. 

Several  small  lymph-nodes  were  I'emoved  from  the  left  groin  under  ether  for  patho- 
logical examination  on  September  1.  From  this  tissue  a  microscopical  diagnosis  of 
malignant  lymphoma  or  lymphosarcoma  was  made,  and  (considering  the  slightly  al- 
tered condition  of  the  blood  at  that  time)  the  possibility  of  its  being  a  case  of  begin- 
ning Hodgkin's  disease  was  considered. 

Three-quarters  of  a  grain  of  citrate  of  iron  was  given  subcutaneously  every  other 
day  throughout  September.  The  general  condition  improved  decidedly  during  the  first 
three  weeks  of  the  month. 

About  this  time  mterference  with  respiration  during  sleep  developed.  The 
breathing  was  noisy,  although  the  mouth  was  kept  closed.  There  was  no  enlarge- 
ment of  the  tonsils  and  no  increase  of  adenoid  tissue  in  the  throat.  The  obstruction 
appeared  to  be  below  the  pharynx.  No  cause  for  the  obstruction  was  found  on  exami- 
nation, and  it  was  thought  that  the  trouble  with  the  respiration  was  due  to  pressure  of 
the  growth  in  the  chest  on  the  nerve  trunks.  A  nasal  discharge  with  a  markedly 
septic  odor  soon  developed.  Cultures  from  both  nose  and  throat  showed  no  Klebs- 
Loeffler  bacilli.  A  firm  new  growth  then  appeared  in  the  posterior  pharynx  and 
increased  somewhat  in  size.  The  obstruction  to  respiration  and  the  nasal  discharge 
with  the  resulting  septic  absorption  caused  a  great  deal  of  difficulty  for  several  weeks  ; 
later  they  were  much  less  troublesome. 

About  the  same  time  that  the  difficulty  with  respiration  appeared,  the  signs  of  a 
new  growth  in  the  chest  began  to  increase.  Dulness  developed  under  the  sternum  and 
to  the  left  of  the  heart.  The  respiration  on  the  right  side  was  as  before.  The  left 
chest  moved  less  than  the  right  and  the  respiration  was  decidedly  diminished  although 
not  changed  in  character.  The  masses  at  the  sides  of  the  face  also  began  to  increase  in 
size,  the  lymph-nodes  throughout  the  body  became  larger  and  new  ones  appeared. 
The  enlargement  of  the  masses  and  lymph-nodes  increased  progressively,  and  during 
the  latter  part  of  September  the  general  condition  fell  off  decidedly. 

Lugol's  solution,  in  doses  of  from  1  to  5  minims  three  times  daily,  was  begun 
about  the  first  of  October  and  continued  until  death. 

Early  in  October  the  gums  became  spongy  and  bleeding  and  fine  petechial  spots 
appeared  all  over  the  body.  A  few  large  ecchymoses  also  appeared  on  the  sacrum  and 
thighs.  About  the  middle  of  October  there  was  a  perforation  of  the  hard  palate  on 
each  side  of  the  median  line  by  a  dark,  soft,  irregular  substance  resembling  a  new 
growth  about  to  break  doAvn.  The  blood  picture  changed  materially  as  regards  the 
differential  count  at  this  time. 

The  diagnosis  of  lymphatic  leukaemia  was  then  made  on  account  of  the  high  per- 
centage of  lymphocytes  in  spite  of  the  comparatively  low  white  count. 

A  gland  was  removed  from  the  left  side  of  the  neck  on  October  17.  The  examina- 
tion of  this  tissue  showed  little  resemblance  to  a  normal  gland  ;  no  follicles  could  be 
distinguished,  and  the  tissue  was  nearly  uniform  throughout  the  section.  With  the 
high  power  (magnification  900  diameters)  there  was  seen  to  be  a  very  great  prolifera- 
tion of  lymphoid  cells.  These  cells  were  not  of  the  type  of  the  usual  small  lympho- 
cytes, but  had  the  characteristics  of  the  cells  in  the  germ  centres  of  the  follicles  and 
other  places  where  there  is  active  proliferation  of  lymphoid  tissue.  These  cells  had 
fairly  large  vesicular  nuclei  and  showed  enormous  numbers  of  mitotic  figures.  In  the 
greater  part  of  the  tissue  there  were  no  other  cells.  There  was  very  little  stroma  and  in 
large  areas  there  was  none  at  all  to  be  seen. 

The  larger  cells,  similar  to  those  seen  in  lymphosarcoma,  were  absent.    There  were 

only  occasional  eosinophiles.     There  were  numbers  of  nucleated  red  blood  corpuscles 

in  the  sinuses. 

57 


898  PEDIATRICS. 

A  diagnosis  of  anaemia  associated  with  lymphatic  hyperplasia  or  acute  lymphatic 
leukaemia  was  made  from  this  examination. 

Several  sections  from  each  specimen  were  also  stained  and  examined  for  tubercle 
bacilli,  but  none  were  found. 

Failure  was  progressive  from  this  time  on.  There  was  a  steady  increase  in  the 
size  of  the  lymph-nodes  with  progressive  failure  in  the  general  condition  and  in  the 
color  of  the  skin  and  mucous  membranes.  The  signs  of  new  growth  in  the  chest  did 
not  increase  a  great  deal,  but  respiration  continued  difficult.  There  were  no  further 
hemorrhages.  The  nasal  discharge  diminished  during  the  last  two  weeks.  The  urine 
was  always  normal.  The  haemoglobin  and  the  number  of  red  corpuscles  diminished 
steadily,  while  the  number  of  white  corpuscles  increased,  reaching  174,600  the  day 
before  death,  which  occurred  on  Nov.  4,  five  months  after  the  onset.  The  percentage 
of  mononuclear  cells  remained  high,  varying,  however,  at  different  examinations.  An 
autopsy  was  refused. 

This  case  is  of  interest  in  that  it  afforded  an  opportunity  to  study  the  development 
of  the  changes  in  the  blood  and  lymph-nodes  during  a  considerable  period,  and  that 
although  it  Avas  most  carefully  studied,  the  correct  diagnosis  could  not  be  made  until  a 
comparatively  short  time  before  death.  It  shows,  however,  that  the  character  of  the 
changes  in  the  blood  may  not  develop  to  a  degree  sufficient  to  justify  a  positive  diagnosis 
for  many  months.  It  also  shows  that  the  changes  in  the  lymph-nodes  may  be,  not 
only  at  first,  but  for  a  considerable  time,  materially  different  from  those  which  are 
usually  considered  to  be  typical  of  this  disease.  It  is  noteworthy  that  the  characteristic 
changes  in  the  blood  and  lymph-nodes  appeared  at  essentially  the  same  time. 

The  only  inference  that  can  be  made  from  the  histological  study  of  these  tissues  at 
different  stages  of  the  disease  is  that  lymphatic  leukaemia  may  have  its  origin  in  a 
malignant  growth  affecting  the  lymphoid  tissues  more  or  less  generally,  and  that  not 
until  there  is  a  secondary  proUferation  of  the  lymphoid  cells  do  we  get  the  typical 
tissue  picture  and  blood  condition  which  is  characteristic  of  lymphatic  leukaemia.  It 
suggests  that  leukaemia,  pseudo-leukasmia  and  malignant  lymphoma  cannot  be  sepa- 
rated as  three  distinct  entities,  and  that  they  do  not  always  differ  characteristically  in 
the  histological  structure  of  their  lymphoid  tissues  ;  also  that  the  microscopical  sections 
in  these  cases  will  be  often  wrongly  judged  in  the  absence  of  complete  clinical  data  as 
regards  the  distribution  of  the  process  and  the  examination  of  the  blood. 

AN^^aVHA  INFANTUM  PSBUDO-LEUK^MIOA. 
Synonyms:  Ansemia  splenica  infettiva  dei  bambini;  ansemia  splenica 
[splenomegalie  primitive] ;  von  Jaksch's  anaemia;  splenic  anaemia  of  infants. 

Definition. — A  condition  occurring  in  infants,  usually  in  the  first  two 
years  of  life,  characterized  by  great  pallor,  considerable  enlargement  of 
the  spleen,  moderate  enlargement  of  the  hver,  a  low  erythrocyte  count, 
usually  a  moderate  leucocytosis,  consisting  chiefly  of  an  increase  of  the 
lymphocytes,  numerous  erythroblasts,  low  haemoglobin,  the  absence  of 
especial  enlargement  of  the  lymph-nodes,  and  at  times  accompanied  by 
hemorrhages  (haematemesis,  hematuria,  purpura)  without  any  known 
cause.     The  course  of  the  disease  is  usually  subacute  or  chronic. 

The  term  "anaemia  infantum  pseudo-leukaemica,"  first  used  by  von 
Jaksch  in  1889,  was  originally  adopted  on  the  ground  that  the  disease 
was  one  form  of  pseudo-leukaemia  (Hodgkin's  disease).  Of  late  years  it 
has  been  so  clearly  shown  to  be  different  from  Hodgkin's  disease,  in  that 
the  condition  of  the  spleen  is  not  the  same,  that  the  name  "pseudo-leu- 


THE   BLOOD    IN   INFANCY   AND   CHILDHOOD.  899 

ksemia"  is  evidently  a  misnomer  and,  strictly  speaking,  should  not  be 
used  in  connection  with  the  class  of  cases  under  consideration.  On  the 
other  hand,  there  are  as  yet  so  much  dispute  and  such  varying  opinions 
among  those  who  have  carefully  studied  the  group  of  symptoms  which 
are  supposed  to  represent  the  disease,  that  there  is  no  other  name  which 
at  present  had  better  be  applied  to  it,  since  the  evidence  is  very  strong 
that  no  such  disease  exists  apart  from  severe  cases  of  secondary  anaemia 
with  enlarged  spleen.  It  is  supposed  at  present  to  correspond  to  the  so- 
called  cases  of  splenic  anaemia  in  adults.  The  same  difference  of  opinion 
exists  as  to  the  recognition  of  a  splenic  anaemia  in  adults  as  separate  from 
severe  cases  of  secondary  anaemia  with  enlarged  spleen. 

Formerly,  anaemia  infantum  pseudo-leukaemica  was  considered  a  pri- 
mary disease  of  the  blood,  but  it  was  soon  differentiated  from  the  dif- 
ferent forms  of  leukaemia,  and  later  from  pseudo-leukaemia  (Hodgkin's 
disease). 

As  far  back  as  1866  a  case  of  a  child  suffering  from  a  severe  form  of 
anaemia  accompanied  by  an  enlarged  spleen  was  reported  by  Gretsel. 
Cases  have  since  been  described,  but  in  a  somewhat  indefmite  manner, 
and  the  next  important  work  which  appeared  on  the  subject  was  that  of 
Banti  in  1883.  Banti,  however,  although  believing  that  anaemia  splenica 
was  a  primary  disease  of  the  spleen,  considers  it  also  a  splenic  form  of 
pseudo-leukaemia,  and  it  is  from  Banti's  description  that  the  characteristic 
symptoms  of  the  disease  are  taken  as  well  as  the  pathology.  Following 
Banti,  a  number  of  writers  have  recorded  cases  which  they  considered 
to  represent  the  disease  splenic  anaemia ;  but  their  cases,  in  the  light  of 
more  modern  investigation,  are  so  closely  allied  in  their  description  to 
those  of  pseudo-leuksemia  that  they  would  at  the  present  time  scarcely  be 
accepted. 

In  1891  Bruhl  published  an  article  on  splenic  anaemia,  and  suggested 
the  name  "splenomegalie  primitive."  Bruhl's  work,  however,  was  very 
much  in  the  same  line  as  Banti's. 

Pathological  Anatomy. — The  pathological  lesions  in  a  case  studied  and 
described  by  Banti  were  marked  fibrous  changes  in  the  trabeculae  and  the 
follicles  of  the  spleen,  and  a  great  diminution  of  the  cells.  There  were  many 
large  phagocytic  cells  containing  red  corpuscles,  the  bone-marrow  was 
red  and  showed  a  lymphoid  condition,  but  the  lymph-nodes  were  not  en- 
larged. The  spleen  weighed  two  pounds  seven  ounces,  the  liver  weighed 
two  pounds  twelve  and  one-half  ounces.  The  blood  showed  a  diminu- 
tion of  leucocytes,  and  the  red  corpuscles  were  between  2,000,0,00  and 
3,000,000  per  cubic  millimetre.  The  temperature  varied  for  four  months, 
sometimes  as  much  as  four  degrees  between  morning  and  evening.  There 
was  no  history  of  rhachitis,  syphiUs,  or  malaria. 

It  is  very  evident  that  there  does  not  seem  to  be  satisfactory  post- 
mortem evidence  to  warrant  a  definite  pathological  condition  representing 
the  splenic  anaemia  of  infants.     There  seems  to  be  present  in  most  cases 


900  PEDIATRICS. 

a  chronic  hyperplasia  of  the  spleen,  while  in  other  doubtful  cases  the 
spleen  is  not  altered.  The  severe  cases  represent  a  symptom-complex, 
which,  in  the  opinion  of  some  Avriters,  is  definite  enough  to  constitute 
a  clinical  type  of  disease.  There  are,  however,  so  many  mild  and  atypical 
cases  Avhich  grade  off  into  the  clinical  picture  of  simple  secondary  anse- 
mia,  that  other  authorities  would  entirely  discard  the  term  "  angemia 
infantum  pseudo-leuksemica  "  and  its  synonyms  from  the  nomenclature. 

Etiology. — In  regard  to  the  etiology  of  anasmia  infantum  pseudo-leu- 
kaemica  nothing  definite  has  been  proved.  Although  pathological  micro- 
organisms, finding  conditions  favorable  for  their  growth  in  the  spleen, 
may,  according  to  Somma,  find  their  way  into  the  circulation  and  thus 
produce  changes  which  are  represented  by  certain  clinical  symptoms,  yet 
there  is  no  doubt  that  the  true  nature  of  the  disease,  if  such  exists,  has 
not  yet  been  discovered.  Nothing  has  ever  been  found  bacteriologically 
to  show  a  direct  relation  between  the  micro-organisms  present  and  the 
production  of  the  disease.  The  association  of  rhachitis  or  congenital 
syphilis  with  anasmia  infantum  pseudo-leukoemica  has  been  noted  in  a 
large  proportion  of  cases,  but  positive  evidence  is  Avanting  that  they  are  the 
direct  cause  of  the  disease.  Some  of  the  severest  cases  show  only  slight 
rhachitis ;  others  have  been  reported  in  which  neither  rhachitis  nor  con- 
genital syphilis  were  present.  The  present  tendency  is  to  consider  the 
ansemia,  the  enlargement  of  the  spleen  and  the  leucocytosis  secondary  to 
some  profound  disturbance  of  nutrition,  the  causes  of  which  may  be 
many. 

Symptoms. — It  is  difficult  to  describe  the  symptomatology  of  a  disease 
which  is  so  closely  identified  with  cases  of  secondary  anaemia  with  en- 
larged spleen,  and  in  wdiich  the  group  of  symptoms  that  are  supposed 
to  represent  anaemia  infantum  pseudo-leuksemica  are  somewhat  diverse. 
Both  sexes  are  ec{ually  liable  to  present  these  symptoms,  and  the  patients 
are  usually  between  the  ages  of  ten  and  eighteen  months ;  one  has  been 
reported  of  seven  and  one-half  months,  and  one  at  three  and  one-half 
years.  The  onset  of  the  disease  is  gradual,  the  nutrition  is  poor ;  there 
are  considerable  emaciation,  a  waxy  tint  of  the  skin,  at  times  hemorrhages 
from  the  mucous  membranes  and  the  skin,  a  much  enlarged  spleen,  and 
a  moderately  enlarged  liver.  There  is  no  tenderness  over  the  bones,  and 
there  are  often  a  venous  bruit  in  the  neck  and  functional  cardiac  murmurs. 
The  blood  shows  the  characteristics  of  a  secondary  anasmia  of  varying 
intensity, — that  is,  a  diminished  number  of  erythrocytes,  which  may  be  as 
low  as  1,000,000  per  cm.,  but  usually  range  between  2,000,000  and 
3,000,000  per  cm.,  low  haemoglobin,  but  not  always  in  proportion  to  the 
reduction  in  the  erythrocytes,  variations  in  the  size  and  shape  of  the 
erythrocytes  and  in  the  number  of  erythroblasts,  which  are  usually 
numerous  and  consist  mostly  of  normoblasts.  There  is  no  definite  rela- 
tionship between  the  degree  of  anaemia  and  the  size  of  the  spleen  or  of  the 
liver.    The  leucocytes  are  not  characteristic,  being  markedly  increased  in 


THE    BLOOD    IX    IXFAXCY   AXD    CHILDHOOD.  901 

some  cases  and  in  ..ormal  proportions  in  others.  Tliey  vary  in  number 
from  normal  to  50.000  per  cm.  In  tlie  majority  of  cases,  the  larger  the 
spleen  the  greater  is  the  leucocytosis,  according  to  Hutchison.  Morse 
dissents  from  this  view.  He  admits  that  the  Lrgest  spleens  usually  occur 
in  connection  with  the  greatest  leucocytosis,  but  in  his  series  he  found 
occasionally  large  spleens  with  no  leucocytosis.  Myelocytes  are  usually 
present  in  small  percentages,  but  not  in  such  numbers  as  to  suggest  a 
myelogenous  leukfemia.  The  lymphocytosis,  reported  by  many  writers, 
may  occur  under  any  condition,  giving  rise  to  an  increased  number  of 
white  cells. 

Diagnosis. — There  seems  to  be  no  doubt  that  antemia  intantum  pseudo- 
leuka?mica  and  aiia?mia  splenica  infettiva  are  the  same  condition,  and.  as 
there  does  not  seem  to  be  reason  for  believing  that  the  spleen  is  primarily 
affected  in  either  of  them,  they  need  not  be  diherentiated  one  from  the 
other.  The  differential  diagnosis  should  first  be  made  from  leukEemia  and 
pseudo-leukfemia.  The  proportionately  low  leucocytosis  and  the  absence 
of  either  a  general  lymphatic  enlargement  or  an  excess  of  myelocytes  in 
the  blood  would  differentiate  it  from  the  former,  while  the  absence  of 
enlarged  lymph-nodes  would  exclude  pseudo-leukaemia.  As  there  are  so 
few  cases  in  which  a  thorough  and  reliable  examination  of  the  organs  has 
been  made  in  which  rhachitis  was  not  present,  the  diagnosis  between 
rhachitis  with  enlarged  spleen  and  secondary  aneemia,  and  this  supposed 
especial  group  of  symptoms,  would  be  impossible. 

We  know  that  in  infants  the  same  blood  changes  which  have  been 
mentioned  above  often  occur  in  connection  with  an  enlarged  spleen  in 
the  course  of  or  following  any  disease  of  nutrition.  AVe  are  therefore  in 
the  position  of  attempting  to  make  a  diagnosis  between  two  conditions 
which  are  practically  the  same.  In  making  a  diagnosis  we  should  limit 
the  term  anasmia  infantum  pseudo-leuksemica  to  those  cases  in  which  no 
cause  for  secondary  antemia  can  be  found,  and  in  which  the  clinical 
symptoms  and  changes  in  the  blood  already  desciibed  are  present. 

Prognosis. — The  prognosis  varies  according  to  the  extent  and  serious 
nature  of  the  cause  which  produces  the  condition.  The  symptoms  run 
an  essentially  subacute  or  chronic  course ;  the  large  size  of  the  spleen 
does  not  necessarily  imply  a  fatal  ending,  and  many  cases  recover.  When, 
however,  secondary  changes  in  the  blood  have  occurred  to  such  an  extent 
as  to  warrant  the  diagnosis  of  a  severe  form  of  anaemia,  and  when  a  spleen 
of  considerable  size  is  detected  in  connection  with  these  blood  changes,  the 
prognosis  is  very  bad,  as  the  infants  usually  die. 

Treatment. — What  has  just  been  said  of  the  prognosis  in  this  class  of 
cases  may  also  be  said  of  the  treatment,  which  is,  in  fact,  that  of  a 
case  of  secondary  ansemia,  and  depends  upon  what  is  most  reasonably 
supposed  to  be  causing  the  condition  that  is  present.  This  may  be 
malaria,  rhachitis,  gastro-enteric  disease,  or  some  unknown  cause  wliich, 
simply  representing  the  conditions  of  ana?mia,  calls  for  the  usual  treat- 


902  PEDIATRICS. 

ment  ot  arsenic,  iron,  proper  food,  and  hygiene,  the  detailed  description 
of  which  Avill  be  found  under  the  heading  of  the  especial  disease  "with 
whicli  tlie  symptoms  are  associated. 

PRIMARY    ANJEMIAS. 

Pernicious  Anaemia. — Tliis  is  the  most  severe  form  of  primary  anae- 
mias, and  is  cliaracterized  by  quite  constant  changes  in  the  blood,  usually 
developing  witliout  evident  cause,  and  a  progressive  course,  leading  to  a 
fatal  termination  in  the  majority  of  cases. 

Etiology. — This  disease  is  much  less  frequent  in  children  tlian  in  adults, 
the  proportion  of  cases  bemg  about  one  to  seventeen.  It  is  less  common 
in  infancy  than  in  later  childhood.  Of  twenty-five  reported  cases,  four 
were  between  the  ages  of  three  months  and  two  years,  four  between 
three  and  five  years,  eiglit  between  six  and  ten  years,  and  nine  between 
ten  and  fifteen  years.  In  tlie  majority  of  cases  no  definite  cause  has  been 
discovered.  In  some,  the  following  etiological  factors  have  been  noted : 
sypliilis,  severe  rhacliitis,  especially  with  splenic  enlargement,  and  intesti- 
nal parasites,  such  as  taenia,  ankylostoma,  and  bothryocephalus,  but  these 
are  not  to  be  considered  as  true  instances  of  pernicious  anaemia.  Hutchi- 
son narrows  the  number  of  cases  to  eleven,  of  which  five  were  probably 
genuine.  The  youngest  of  these  occurred  at  the  age  of  nine  months  and 
is  the  only  one  which  recovered.  It  is  reported  below.  The  best  theory 
for  the  explanation  of  the  condition  seems  to  be  that  of  a  toxic  haemolysis. 
There  are  evidences  in  the  urine,  blood,  and  tissues,  of  increased  destruc- 
tion of  blood-cells,  and  also  of  a  compensating  hypertrophy  in  the  blood- 
forming  organs.  There  is  considerable  evidence  that  the  alimentary  tract 
is  the  source  of  the  unknown  toxins  causing  haemolysis. 

Pathological  Anatomy. — The  body  is  not  often  emaciated.  The  skin 
usually  shows  a  lemon-yehow  tint.  There  is  marked  aucemia  of  the  organs 
at  times,  with  many  capillary  hemorrliages  into  the  organs  and  skin.  The 
heart  is  large  and  flabby,  and  shows  mtense  fatty  degeneration.  The  liver 
is  fatty  and  sometimes  enlarged.  The  kidneys  and  blood-vessels  show 
fatty  changes.  One  of  the  most  characteristic  features  is  a  deposit  of  iron 
in  the  liver  tissue  and  often  in  the  intestinal  mucosa.  The  spleen  is  hard 
and  somewhat  increased  in  size  as  a  result  of  overgrowth  of  the  fibrous 
tissue  of  the  pulp.  Some  of  the  lymph-nodes  are  often  enlarged.  The 
bone-marrow  is  '■splenified," — that  is,  returned  to  its  embryonic  state. 

Symptoms. — Blood. — The  red  corpuscles  are  much  diminished,  usually 
to  one  million,  sometmies  even  to  five  hundred  thousand.  The  hsemo- 
globui  is  dimmished  per  bulk  of  the  blood,  often  to  twenty-five  or  thirty 
per  cent.,  rarely  to  twelve  or  fifteen  per  cent.,  but  owing  to  the  greater 
reduction  of  red  cells  it  is  often  relatively  increased  per  corpuscle  (the 
color  index  is  high  and  sometimes  greater  than  normal).  Tliis  is  exactly 
the  opposite  condition  to  that  which  occurs  in  chlorosis.  The  red  cells 
show  great  variation  in  shape  and  size,  many  oval  or  rod-shaped  or  irreg- 


THE    BLOOD    IX    IXFAXCY    AXD    CHILDHOOD.  903 

ular  coqiLiscles  are  present,  which  take  stains  in  an  uneven  way.  A 
majority  of  the  red  cehs  are  larger  than  normal  (megalocytes).  Many 
nucleated  red  cells  are  present,  both  of  normal  size  (normoblasts)  and  of 
lai^er  size  (megaloblasts).  The  megaloblasts  are  the  more  numerous  of 
the  two.  Many  of  the  nuclei  are  found  in  a  process  of  division  (kan'o- 
Jdnesis).  The  leucocjies  are  normal  in  number,  or  somewhat  diminished, 
— eight  thousand  to  four  thousand.  In  the  more  severe  cases  there  is  fre- 
quently a  relative  mcrease  of  the  lymphocytes  with  a  corresponding  dimi- 
nution of  the  pohmuclear  cells.  A  few  myeloceles  are  not  infrec{uently 
found. 

The  general  symptoms  are  those  of  severe  anaemia,  increasing  pallor 
and  prostration,  usually  "without  emaciation.  The  onset  is  insidious,  and 
the  clinical  course  does  not  differ  from  that  of  adults.  There  is  fre- 
quently more  or  less  gastro-enteric  disturbance,  vomitmg,  nausea,  or 
dyspnoea.  Hemorrhages  occur  into  the  skin  or  from  the  nasal  and  other 
mucous  membranes.  tEdema  often  appears  in  the  dependent  portions  of 
the  skin,  less  frecpently  in  the  cavities  of  the  body.  Haemic  murmurs  are 
usually  heard  in  the  cardiac  region.  The  pulse  is  full  and  soft.  It  is  to 
be  noted  that  hsmic  murmurs  are  less  frequent  in  the  ansemia  of  infants 
than  in  that  of  adults.  The  urme  is  scanty  and  of  low  specific  gravity. 
The  temperature  is  variable ;  at  times  it  may  be  normal,  and  at  others  an 
irregular  pyrexia  may  run  for  a  considerable  period.  The  course  is  a 
chronic  one,  but  varies  in  length.  The  disease  may  be  completely  devel- 
oped in  some  cases  in  two  or  three  months,  and  in  others  only  after  ten 
or  twelve  months.  In  most  instances  it  progresses  steadily  to  a  fatal 
termination. 

Diagnosis. — The  diagnosis  from  other  forms  of  anaemia  is  made  chiefly 
by  the  blood  examination.     The  characteristic  features  are  : 

(1)  Great  diminution  in  the  number  of  red  cells. 

(2)  Pvelative  mcrease  of  htemoglobtn  per  corpuscle. — high-color  index. 
(3j  Irregularity  of  distribution  of  haemoglobin  in  the  red  cells. 

(4)  Marked  irregularity  in  form  and  size,  and  a  general  increase  in 
size  of  the  red  cells. 

(5)  An  excess  of  megaloblasts  over  normoblasts. 

(6)  A  normal  or  diminished  leucocei:e  count. 

These  changes  in  the  blood  must  be  in  one  in  whom  no  cause  for  a 
secondary  anaemia  can  be  discovered,  for  in  infancy  a  severe  secondary 
ansemia  may  assume  the  blood  characteristics  of  pernicious  anaemia. 

Prognosis — The  prognosis  is  almost  absolutely  fatal,  except  in  those 
cases  associated  with  intestinal  parasites  or  rhachitis,  although '  lately, 
when  arsenic  has  been  given,  the  proportion  of  recoveries  has  increased. 
The  blood  examination  is  a  valualile  index  to  the  prognosis.  The  pres-* 
ence  of  many  normoblasts  is  hopeful,  pointing  to  a  regeneration  of  the 
bone-marrow.  The  presence  of  a  large  excess  of  megaloblasts  indicates 
a  more  malignant  case. 


904  PEDIATRICS. 

Treatment. — Arsenic  is  more  useful  than  iron  in  this  form  of  anaemia. 
It  is  usually  well  borne,  and  should  be  given  in  small  doses,  gradually- 
increased  to  the  limit  of  tolerance.  A  child  of  ten  years  can  usually 
take  2  c.c.  (30  minims)  of  Fowler's  solution  in  the  twenty-four  hours. 
Arsenic  may  also  be  given  in  pill  form.  Active  exercise  should  be  pro- 
hibited and  replaced  by  massage,  which  is  of  great  value  and  never  to  be 
neglected.  Rest  in  bed,  either  absolute  or  for  the  greater  part  of  the 
time,  is  essential.  Small,  frequent,  and  regular  meals  should  be  given,  of 
light,  nutritious  food.  Bone-marrow  in  the  form  of  a  glycerin  extract  has 
been  recommended,  but  has  thus  far  proved  of  doubtful  value.  The  free 
administration  of  oxygen  day  and  night  for  several  weeks  is  worthy  of 
trial,  if  expense  is  not  to  be  considered.  We  have  had  one  case  in  which 
the  red  cells  had  fallen  to  1,088,000  and  the  haemoglobin  to  20  per  cent. 
Rapid  improvement  in  the  blood  followed  this  treatment  when  carried 
out  for  over  four  weeks,  and  the  blood  eventually  became  normal. 

The  following  case  of  pernicious  anaemia  occurred  in  our  practice  and 
is  of  especial  interest  in  that  it  is  the  only  case  in  an  infant  which  has 
apparently  made  a  complete  recovery : 

J.  T. ,  a  girl  born  on  December  1.  1899,  has  been  under  our  observation  from  the 
day  of  her  birth  until  the  present.  The  family  history  is  negative.  The  birth  weight 
was  seven  and  one-half  pounds.  At  the  end  of  sixteen  weeks  of  breast  feeding  she 
weighed  13  pounds  and  7  ounces.  When  the  infant  was  three  weeks  old  the  mother 
developed  a  mild  case  of  mastitis.  At  the  end  of  the  fourth  month,  although  the 
mother  had  plenty  of  milk  the  child  began  to  lose  in  weight  and  show  symptoms  of 
intestinal  indigestion,  which  increased  so  much  that  it  was  found  necessary  to  adopt  a 
substitute  food.  She  was  then  put  on  a  laboratory  mixture  of  4  per  cent,  fat,  7  per 
cent,  sugar,  and  1  per  cent,  pi'oteids.  On  this  she  again  gained  one  pound  in  weight  in 
ten  days  and  the  indigestion  ceased.  She  appeared  absolutely  well.  At  five  months 
she  had  a  mild  attack  of  measles  from  which  she  made  a  speedy  and  complete  recovery. 
At  the  end  of  six  months  she  weighed  161  pounds.  During  the  hot  months  of  June, 
^July,  and  August  there  were  several  mild  attacks  of  intestinal  indigestion,  during  which 
the  milk  was  temporarily  weakened.  In  October,  when  ten  months  old,  her  digestion 
Avas  normal  and  she  was  taking  a  4  per  cent,  fat,  7  per  cent,  sugar,  2  per  cent,  proteid. 

It  is  impossible  to  state  when  the  symptoms  of  pernicious  anaemia  began.  If  the 
occasional  indigestion  in  the  months  of  July  and  August  had  any  bearing  on  the  sub- 
sequent disease,  there  was  nothing  in  the  infant's  physical  condition  to  indicate  any 
serious  trouble,  and  repeated  physical  examinations  failed  to  excite  any  suspicion  of  a 
serious  underlying  disease. 

During  the  latter  part  of  September,  however,  when  the  infant  was  a  little  over 
nine  months  of  age,  she  was  noticed  to  fail,  not  at  all  rapidly,  but  on  the  contrary,  in 
a  very  insidious  manner.  Indigestion  again  set  in.  The  child  began  to  have  a  raised 
temperature  and  a  slight  coryza.  There  was  some  fretfulness  and  restlessness,  which 
could  easily  have  been  explained  by  a  disturbance  due  to  dentition.  The  indigestion 
ceased  for  two  weeks.  Then  came  a  period  of  malaise  and  loss  of  strength.  She 
grew  pale,  the  pallor  becoming  more  and  more  noticeable  as  the  tan  of  the  summer 
wore  off. 

On  November  4th,  when  ten  months  old,  the  pallor  had  become  quite  pronounced, 
and  the  hands  and  feet  were  noticed  to  be  slightly  puffed.  The  temperature  was  100° 
F.  both  morning  and  evening. 


THE   BLOOD   IN   INFANCY   AND    CHILDHOOD.  905 

On  November  5th,  a  physical  examination  was  again  made.  Pronounced  pallor, 
general  weakness  and  a  faint  systolic  murmur  heard  all  over  the  precordia  and  in  the 
neck,  without  any  cardiac  enlargement,  and  considerable  puffiness  of  the  face,  legs, 
ankles,  feet  and  hands  were  the  only  signs  of  importance.  The  murmur  had  not  been 
noticed  before.  There  were  no  evidences  of  rhachitis  or  scorbutus,  and  no  subcu- 
taneous hemorrhages.  There  was  no  glandular  enlargement  to  be  detected,  the  spleen 
not  being  palpable  and  giving  the  normal  percussion  limits. 

An  examination  of  the  urine  showed  only  the  slightest  possible  trace  of  albumin 
without  blood  or  casts. 

The  blood  examination,  on  November  5th,  was  haemoglobin,  30  per  cent. ;  red  blood 
corpuscles,  1,732,000;  white  blood  corpuscles,  9,200.  A  differential  count  of  500 
cells  showed  :  Polymorphonuclear  neutrophiles,  32  per  cent. ;  lymphocytes,  large  and 
small  (small  lymphocytes  in  excess  of  the  large  round  cells),  66.2  per  cent.;  eosino- 
philes,  1.8  per  cent.  During  the  count  3  megaloblasts  and  3  normoblasts  were  seen. 
There  were  numerous  poikilocytes  and  cells  of  pyriform  and  oval  shape.  There  were 
many  large  red  corpuscles  or  macrocytes.  The  average  diameter  of  the  red  blood 
corpuscles  was  distinctly  increased  as  compared  with  the  normal,  although  there  were 
some  abnormally  small  cells,  or  microcytes.  The  color  index  of  the  individual  cells 
was  difficult  to  judge  owing  to  the  fact  that  the  spreads  were  somewhat  overheated. 

The  examination  of  the  blood  showed  beyond  question  the  presence  of  either  a  very 
severe  secondary  anaemia  or  of  a  primary  or  pernicious  anaemia.  The  blood  by  itself 
was  strongly  suggestive  of  the  pernicious  type. 

Every  effort  was  made  to  determine  a  cause  for  a  secondary  anaemia.  The  urine 
and  several  specimens  of  wall  paper  and  carpets  were  examined  for  arsenic  with 
negative  results.  Every  possible  source  of  poisoning,  such  as  the  cooking  utensils,  was 
investigated,  but  no  good  evidence  of  any  could  be  obtained.  The  fecal  discharges  were 
inspected  daily,  and  there  was  no  suggestion  of  intestinal  parasites.  The  attacks  of 
indigestion  had  never  been  severe,  and  the  splendid  nutrition  of  the  infant  for  nine 
months  of  its  life  on  a  food,  first  of  breast-milk  for  four  months  and  then  a  carefully 
supervised  modified  milk,  eliminated  improper  food  as  a  cause  of  anaemia.  It  was, 
therefore,  impossible  for  us  to  discover  any  rational  cause  for  so  extreme  a  degree  of 
anaemia  and  weakness. 

The  infant  failed  steadily  ;  the  loss  in  strength,  the  increasing  oedema  and  the 
intensification  of  the  ha;mic  murmur  being  the  principal  signs  of  importance.  The 
temperature  varied  between  99.5°  and  100°.  The  food  was  well  digested.  There  was 
some  loss  of  weight,  but  no  emaciation.     There  was  no  vomiting  and  no  diarrhcea. 

The  treatment  consisted  of  iron,  brandy,  and  careful  nursing  and  feeding. 

Although  there  was  no  evidence  which  suggested  that  the  milk  supply  was  in  any 
way  responsible  for  the  severe  and  progressive  condition  of  anaemia  and  loss  of 
strength,  milk  was  obtained  from  another  herd  of  cows,  and  cereals  and  broths  were 
tried,  but  as  both  of  the  latter  caused  symptoms  of  gastric  indigestion  they  were 
discontinued. 

For  two  Aveeks  the  temperature  (rectal)  ranged  from  99.6°  to  101°,  and  then 
became  higher  and  more  irregular,  on  several  occasions  reaching  103°  F.  The  pulse 
became  more  rapid  and  at  times  was  irregular. 

On  November  20th,  there  was  a  slight  collapse,  the  pulse  suddenly  rising  to  200 
and  becoming  very  weak,  and  the  respirations  to  between  50  and  60  per  minute.  The 
child  was  sleepy,  weak  and  languid.  The  swelling  of  the  feet,  hands  and  eyes  were 
more  pronounced.  The  loss  of  weight  in  one  week  amounted  to  1^  pounds.  The 
pallor  was  at  this  time  extreme  and  of  a  grayish  color.  The  heart's  action  was 
irregular,  and  the  systolic  murmur  loud  and  transmitted  in  all  directions.  The  physical 
examination  revealed  nothing  new.  There  was  no  chill,  cyanosis,  nor  evidence  of 
hemorrhage  from  any  source. 


906 


PEDIATRICS. 


On-  November  21st,  another  complete  examination  of  the  blood  was  made,  which 
showed  a  rapid  deterioration  of  the  blood  in  the  three  weeks  which  had  elapsed  from 
the  first  examination.  It  was  as  follows  :  Haemoglobin,  20  per  cent. ;  white  blood 
corpuscles,  18,800;  red  blood  corpuscles,  1,088,000;  Widal  reaction,  negative;  ex- 
amination for  Plasmodia,  negative. 

The  color  index  of  the  individual  red  blood  corpuscles  in  both  the  fresh  and 
stained  preparations  was  nearly  normal,  and  Avas  relatively  high  as  compared  with  the 
great  diminution  in  the  red  blood  corpuscles. 

Differential  count,  500  cells:  polymorphonuclear  neutrophiles,  43.4  per  cent.; 
lymphocytes  (small  lymphocytes  being  in  excess  of  the  large  and  transitional  forms), 
54.2  per  cent.;  eosinophiles,  0.6  per  cent.;  myelocytes,  1.8  per  cent 

The  course  of  the  ana?mia  is  shown  in  the  following  chart  : 


CHAET 

33. 

1 

Hgb.  1       REDS. 

NOV.            DEC.            JAN.            FEB. 

MAR. 

AP?!.       '       WAY 

5       21    .     5           19        2        16    30   1     1     20 

1 

21                                          18' 

120 

6.000,000 

1     1     1     1 

1 

1     1     1     1                1      '      1     ' 

ill' 

1 

[     1               _*.— ^  1 

110 

5,500,000 

1^1. 

i    ^_^-.— ■"''^ 

1            1 

1       :                                                              !       ■       1       -^ 

'"^ 

!       1 

ICO              5.000.000 

UJ                                              t     '     ^"^ 

i       1 

1    ,          .                1  ^^                       ,    1    .    1    1    1   1   1   1 

90              4,500,000 

i 

\                                                ''                   !                                                                                            ■          1          1           !          1          1          1 

1 

\  \   ^^                             i  1      .  i  1  1  1 

80              4,000,000 

t  .^"^                                                                             ^               '      '      ■      1 

i 

f^    ill _—-''' 

1 

70               3,500,000 

/  i  1  1  1  >^'.  1  i  1  >  { 

1  /   j  /^ 

1 

1 

1    1 

60              3,000,000 

/   /^ 

50              2,500,000 

/ 

/ 

/ 

40               2,000.000 

1  /I 

r 

, 

/^ 

30              1,500,000 

\_ 

/  / 

1 

*0\  /y 

1 

20              1,000,000 

[52>  1 

1 

1 

1 

10                  500.000 

1 

[ 

1 

0    ;                  0 

1   1 

1 

!      1 









WHITES 

1     1     1     1     1 

— 

1     1     1     1 

19,000 

1     1     1 

,»    i     1 

17,000 

/\  1     1 

'       1     V.l     1 

15,000                   1        !/ 

A 

1 

1 

\ 

/ 

1 

i 

13,000                       / 

A 

\ 

1 

i 

1 

1     ,  ; 

A  / 

1 

^ 

1 

1 

i 

1 

11,000          1      i/ 

1  V 

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5-S^T / 

1  ■  1       1       1       1       .         -^-J : l-J 

_=L^ 

, 

__ 

— 

— 

— 



— 

— 

— 

— ^ 







' 



Upper  black  line  shows  number  of  red  blood  corpuscles  per  c.mm.     Middle  dotted  line  shows  per- 
centage of  haemoglobin.    Lower  dotted  line  shows  number  of  white  blood  corpuscles  per  c.mm. 


During  this  count  there  were  seen  9  megaloblasts  and  3  normoblasts.  The  average 
diameter  of  the  red  cells  was  much  increased.  There  was  considerable  poikilocytosis. 
The  presence  of  very  large  cells  or  macrocytes  Avas  marked,  and  many  of  the  cells  were 
oval  and  pyriform  in  shape.     There  was  moderate  polychromatophilia. 

The  character  of  the  blood  was  by  this  examination  shown  beyond  any  question  to 
be  typical  of  the  blood  of  pernicious  anaemia  in  adults,  in  all  respects  except  for  the 
presence  of  a  low  white  count.  The  tendency  to  an  increase  in  the  white  cells  in 
almost  any  severe  pathological  process  in  infants  is  so  well  known,  however,  that  no 
special  significance  can  be  attached  to  this  variation  from  the  adult  type  of  blood  in 
pernicious  anaemia. 

The  infant  was  at  this  time  so  weak  that  she  could  not  raise  her  legs  or  head  and 
could  scarcely  move  her  arms.  The  general  condition  was  such  that  the  gravest  fears 
were  entertained  regarding  the  result.  At  this  time,  November  2l3t,  the  inhalation  of 
oxygen  was  tried,  the  oxygen  being  given  for  ten  minutes  every  twenty  minutes  day  and 
night,  whether  the  infant  was  asleep  or  awake.      Coincidently  with  this  treatment  a 


THE  BLOOD  IN  INFANCY  AND  CHILDHOOD.  907 

marked  change  took  place  in  the  condition  of  the  infant,  as  was  seen  by  the  gradual 
defervescence  of  the  temperature,  by  the  steady  improvement  in  the  rate  and  quality  of 
the  pulse,  and  by  the  perfectly  evident  improvement  in  the  color  and  strength.  The 
food,  which  was  of  the  same  quality  as  in  the  previous  three  weeks,  was  taken  with 
more  vigor,  the  apathy  became  less  marked,  and  the  infant  took  more  notice  of  what 
was  going  on  about  her. 

The  subsequent  history  of  the  case  was  one  of  steady  improvement,  interrupted  only 
by  a  slight  serous  otitis  media,  a  few  attacks  of  coryza  and  one  of  influenza.  The  color 
improved,  the  strength  returned,  the  systolic  murmur  and  the  oedema  disappeared,  and 
the  infant  began  to  gain  in  weight.  Its  maximum  weight  during  the  summer  was 
twenty-five  pounds  ;  at  the  height  of  its  disease,  i.  e.,  on  November  21st,  it  was  about 
nineteen  pounds.     The  child  is  now  seven  years  old  and  in  perfect  health. 

The  important  points  to  be  emphasized  in  this  particular  instance  are  :  (1)  The 
insidious  onset  with  moderate  and  paroxysmal  attacks  of  indigestion.  (2)  The  extreme 
pallor  and  great  loss  of  strength.  (3)  The  absence  of  any  possible  demonstrable  cause 
for  a  secondary  anaemia.  (4)  The  slightly  elevated  temperature  for  months.  (5)  The 
absence  of  glandular  or  splenic  enlargement.  (6)  The  presence  of  the  pronounced 
typical  characteristics  of  the  blood  of  pernicious  anaemia.  (7)  The  absence  of  any 
considerable  degree  of  leucocytosis  and  of  splenic  or  lymphatic  enlargement.  (8)  The 
rapid  improvement  in  the  general  symptoms  and  in  the  character  of  the  blood  until  the 
infant  in  all  respects  appeared  absolutely  sound  and  healthy. 

Chlorosis. — Chlorosis  is  a  primary  anaemia  of  miknown  cause,  char- 
acterized by  a  marked  diminution  in  the  haemoglobin  in  the  blood  without 
a  corresponding  loss  in  the  number  of  red  cells.  It  is  a  disease  which 
appears  in  girls,  especially  blondes,  between  the  ages  of  twelve  and  seven- 
teen years.  Cases  undoubtedly  occur,  although  not  frequently,  in  infants 
toward  the  end  of  the  first  and  during  the  second  and  third  year,  ex- 
hibiting all  the  characteristic  blood  changes  which  are  seen  in  young 
women,  and  even  hoemic  murmurs.  The  essential  cause  is  unknown.  It 
is  chiefly  seen  in  overworked  girls  living  amid  poor  hygienic  surroundings. 
Psychical  disturbance,  such  as  grief,  worry,  and  fright,  are  important 
factors.  Clark  has  stated  that  the  condition  is  a  copraemia  due  to  toxic 
absorption  (ptomaines  and  leucomaines)  from  the  intestine. 

Pathological  Anatomy. — Chlorosis  is  rarely  fatal.  In  some  cases  hy- 
poplasia of  the  heart,  large  vessels,  ovaries,  and  uterus  have  been  found, 
also  considerable  fatty  degeneration  of  the  heart  and  of  the  intima  of  the 
vessels.     Gastric  ulcer  has  been  occasionally  associated  with  it. 

Symptoms. — The  essential  change  in  the  blood  is  a  marked  loss,  in  the 
individual  red  corpuscle,  of  the  haemoglobin,  which  is  often  only  40  per 
cent.,  and  in  severe  cases  below  30  per  cent.  The  specific  gravity  of  the 
blood  may  be  reduced  to  1025,  although  usually  not  below  1035.  The 
red  cells  in  a  few  cases  are  normal ;  in  the  majority  they  are  reduced  to 
4,000,000  or  may  be  even  lower.  The  red  corpuscles  may  be  very  irregu- 
lar in  size  and  shape  in  severe  cases,  and  may  have  an  average  size  which  is 
less  than  normal.  Nucleated  red  cells  are  often  seen,  but  in  very  small 
numbers,  usually  normoblasts,  rarely  megaloblasts.  Leucocytosis  is  not 
present.    The  onset  of  chlorosis  is  gradual,  the  course  chronic,  and  relapses 


908  PEDIATRICS. 

are  common.  The  symptoms  are  those  of  a  shiiple  amigmia.  The  patient 
complains  of  shortness  of  breath  on  exertion,  and  attacks  of  palpitation  and 
syncope  are  common.  The  appetite  is  poor  or  perverted,  and  there  is  a 
craving  for  unusnal  and  indigestible  articles  of  diet.  Gastric  hyperacidity  is 
often  present,  and  almost  always  constipation.  Enteroptosis  is  not  uncom- 
mon. The  patient  frequently  complains  of  headache  or  neuralgic  pains. 
Hysterical  manifestations  may  occur.  The  menstrual  function  is  often  dis- 
turbed ;  the  flow  is  scanty,  irregular,  and  sometimes  painful.  The  patient  is 
usually  plump  and  soft,  and  the  skin  has  a  peculiar  greenish-yellow  tint 
which  gives  the  disease  its  popular  name  of  "greensickness.'"  Systolic 
murmurs  are  frequently  heard  over  the  heart  in  the  pulmonary  or  mitral 
region,  and  also  a  venous  hum,  the  "  bruit  de  diable,*'  in  the  veins  of  the 
neck.  Palpitation  is  occasionally  seen  in  the  jugular  veins.  There  is  a  ten- 
dency to  venous  thrombosis,  Avliich  most  often  occurs  in  the  femoral  veins. 
The  pulse  is  full  and  soft.  Occasionally  tliere  is  some  puffiness  of  the 
face,  and  often  oedema  of  the  ankles.  The  spleen  may  be  slightly  en- 
larged. The  urine  rarely  contains  a  slight  trace  of  albumin.  Gastric 
ulcer  sometimes  occurs  as  a  complication. 

Diagnosis. — The  age  and  sex  of  the  patient,  the  well-nourished  con- 
dition, the  pearly  sclerotics,  the  color  of  the  skin,  and  the  character  of 
the  blood  form  a  striking  clinical  picture  which  easily  distinguishes  chlo- 
rosis from  other  forms  of  anaemia. 

Prognosis. — The  prognosis  is  almost  always  good.  The  disease  often 
lasts  a  year  and  relapses  are  common.  Chlorosis  is  rarely  fatal,  except 
when  complicated  by  tuberculosis  or  gastric  ulcer. 

Treatment. — There  are  few  therapeutic  measures  in  medicine  more 
satisfactory  than  the  use  of  iron  in  chlorosis.  In  infants  the  iron  can  be 
given  in  the  form  of  the  saccharated  carbonate,  0.12,  0.18,  or  0.24 
gramme  (2,  3,  or  4  grains),  or  of  the  tartrate  of  u'on  and  potash.  Lactate 
^of  iron  can  also  be  given  to  older  individuals  in  doses  of  0.06  to  0.12 
gramme  (1  to  2  grains),  gradually  mcreased  to  0.24  to  0.36  gramme  (4  to 
6  grains),  three  times  a  day.  Ovoferrin  2  c.c.  (0.5  drachm)  to  an  infant  of 
one  year,  is  a  very  unirritating  and  useful  preparation  of  a  true  inorganic 
iron.  The  administration  of  iron  is  usually  followed  by  a  rapid  increase  in 
the  number  of  red  cells  to  the  normal  or  even  above  it.  The  haemoglobin, 
however,  increases  more  slowly.  When  iron  is  not  tolerated,  arsenic  can 
be  given  in  the  form  of  Fowler's  solution.  When  the  iron  causes  con- 
stipation, it  should  be  accompanied  or  followed  Avith  a  saline  or  with 
some  preparation  of  rhubarb.  A  change  of  scene  is  often  beneficial,  and 
later  an  out-of-door  life  and  moderate  exercise. 

SECONDARY  AN^IMIAS. 
Under  the  title  of  secondary  anaemia  we  include  anaemia  resulting 
from  many  kinds  of  pathological  processes  in  the  body  which  occur  out- 
side of  the  blood-forming  organs. 


THE   BLOOD   IN   INFANCY   AND    CHILDHOOD.  909 

Etiology. — Almost  every  disease  of  any  organ  in  the  body  may  produce 
a  secondary  anaemia,  and  it  is  of  high  or  low  grade  according  to  the  severity 
of  the  disease.  There  are  two  important  factors  in  the  process, — namely, 
an  insufficient  production  of  blood  on  account  of  poor  food  or  poor  assimi- 
lation, and  the  increased  destruction  of  blood  as  it  occurs  in  many  wasting 
diseases.  The  aneemia  of  infancy  may  be  either  congenital  or  accjuired. 
The  congenital  forms  are  inherited  from  delicate  or  anaemic  parents,  or 
from  a  mother  who  has  suffered  with  syphilis,  tuberculosis,  or  malaria 
during  her  pregnancy.  Of  the  acquired  anaemias,  a  comparatively  small 
number  of  cases  occur  after  hemorrhage,  as  in  epistaxis,  haemophilia, 
purpura,  or  scorbutus.  The  more  frequent  causes  of  anasmia  in  infants 
and  young  children  are  disturbances  of  digestion  and  assimilation,  such  as 
are  represented  by  inanition  and  chronic  indigestion  resulting  from  im- 
proper quantity  and  quality  of  the  food.  In  bottle-fed  infants  prolonged 
feeding  on  modifications  Avith  very  low  proteids  is  a  fruitful  cause  of 
anaemia.  An  over-rich  food  may  produce  the  same  effect  by  the  production 
of  indigestion  and  subsequent  malnutrition.  Anaemia  may  also  result 
from  chronic  intestinal  affections,  constitutional  conditions  resulting  from 
unhygienic  surroundings,  bad  air,  close  confinement,  general  debility, 
rhachitis,  and  also  from  malignant  disease.  Another  cause  is  found  in 
the  drain  on  the  albumin  of  the  blood  occurring  in  chronic  suppuration, 
nephritis,  and  effusions,  and  still  another  in  the  toxaemia  produced 
by  mineral  poisons,  such  as  arsenic  or  lead,  or  by  infectious  diseases, 
such  as  septicaemia,  diphtheria,  scarlet  fever,  syphilis,  malaria,  and  tuber- 
culosis. 

Symptoms. — Luzet  divides  the  ansemias  of  infancy  into  two  classes, — 
those  with  splenic  enlargement  and  those  without, — and  states  that  the 
first  form  is  more  severe,  and  that  the  blood  in  these  cases  contains  a 
larger  number  of  nucleated  red  cells.  This  classification  is  not  a  very 
satisfactory  one,  for  we  find  very  severe  antemias  without  splenic  enlarge- 
ment, and  also  marked  splenic  hypertrophy  in  many  cases  of  mild  anaemia. 
Monti  and  Berggriin  propose  another  classification,  which  is  more  satis- 
.factory.     They  divide  all  secondary  anaemias  into  four  classes  : 

(1)  Ililcl  ancemias. 

(2)  3Iild  ancemias  with  leucocytosis. 

(3)  Severe  ancemias. 

(4)  Severe  ancemias  with  leucocytosis. 

In  the  mild  anaemias  there  is  a  moderate  diminution  in  the  specific 
gravity  of  the  blood,  in  the  htemoglobin,  and  in  the  red  cells,  and  the  latter 
show  practically  no  changes  in  size  and  in  shape.  In  the  severe  anaemias 
there  is  a  marked  diminution  in  the  specific  gravity,  liEemoglobin,  and  red 
cells,  and  the  latter  show  considerable  changes  in  size  and  form  (poikilo- 
cytes,  normoblasts,  megaloblasts).     The  difi'erence  between  these  two  types 


910  PEDIATRICS. 

is  one  of  degree.  Either  form  may  be  associated  with  leucocytosis,  and  the 
forms  witli  leucocytosis  are  much  more  common  than  tliose  without,  and 
are  almost  invariably  the  more  severe.  The  leucocytosis  is  often  due 
either  to  the  primary  cause  of  the  anaemia  or  to  a  complication,  the  com- 
monest of  which  is  broncho-pneumonia.  In  very  young  infants  the 
increase  in  the  leucocytes  often  consists  of  an  excess  of  lymphocytes, 
especially  in  the  anaemias  dependent  upon  chronic  gastro-intestinal  dis- 
turbances. This  is  possibly  due  to  the  overaction  oi  the  lymphatic 
system  in  these  conditions.  In  all  but  the  mild  anaemias  without  leu- 
cocytosis the  spleen  may  be  enlarged.  The  number  of  red  cells  varies 
from  normal,  in  the  mild  cases,  to  two  million  in  the  severe,  the  spe- 
cific gravity  from  1056  to  1035,  the  haemoglobin  from  eighty  to  thirty  per 
cent.,  the  white  count  from  normal  to  sixty  thousand.  In  secondary  anae- 
mia the  reduction  in  the  total  amount  of  haemoglobin  is  almost  always 
proportionately  greater  than  in  the  corpuscles  (chlor-anaemia).  In  gen- 
eral, the  more  severe  the  anaemia  the  lower  is  the  specific  gravity  of  the 
blood,  the  greater  is  the  variation  in  size  and  shape  of  the  red  cells  (poi- 
kilocytosis),  and  the  more  numerous  the  nucleated  red  cells.  These  last 
are  much  more  abundant  in  children  than  in  adults  with  a  corresponding 
grade  of  anaemia.  In  these  cases  we  have  the  familiar  clinical  picture  of 
pallor,  soft  muscles,  digestive  disturbance,  fretfulness,  headaches,  insom- 
nia, fatigue,  and  breathlessness  on  exertion.  Occasionally  epistaxis  is 
associated  with  the  signs  and  symptoms  of  the  primary  disease.  Haemic 
murmurs  are  usually  heard  over  the  heart  and  the  vessels  of  the  neck. 
(Edema  is  more  common  in  older  children  than  in  adults. 

Diagnosis. — In  the  diagnosis  of  these  anaemias  the  recognition  of. the 
cause  is  very  important.  The  diagnosis  from  the  so-called  primary 
anaemias  is  sometimes  quite  simple,  by  means  of  the  blood  examination, 
especially  in  older  children ;  in  young  children  it  is  often  very  difficult,  as 
~a  result  of  certain  factors  which  have  already  been  mentioned, — namely, 
the  frequency  of  splenic  hypertrophy  in  all  forms  of  anaemia,  the  ease 
with  which  a  leucocytosis  is  developed,  the  frequent  occurrence  of  abun- 
dant myelocytes  and  nucleated  red  cells,  and  the  fatality  of  all  severe 
anaemias  in  children ;  in  short,  the  exaggeration  of  all  blood  changes  in 
infants  and  young  children. 

Prognosis. — The  prognosis  depends  on  the  ag-e,  cause,  and  condition 
of  the  blood.  The  course  of  the  anaemia  is  usually  several  months. 
Traumatic  cases,  which  are  rare  in  childhood,  are  the  most  benign,  since 
in  these  cases  the  blood  is  readily  restored  to  its  normal  condition.  The 
group  of  cases  w^hich  depend  on  toxaemia  or  a  drain  of  the  albumin  of 
the  blood,  such  as  in  suppuration,  fever,  or  from  other  causes,  are  diffi- 
cult to  treat,  unless  the  cause  can  be  removed.  The  severe  cases  may 
develop  into  a  pernicious  anaemia  or  a  leukaemia,  but  death  occurs  more 
commonly  as  a  result  of  some  complicating  disease  rather  than  of  the 
anaemia  itself.    The  prognosis  is  naturally  less  favorable  in  cases  in  which 


THE   BLOOD   IN   INFANCY   AND    CHILDHOOD.  911 

the  haemoglobin  is  reduced  to  30  per  cent,  or  less,  and  the  red  cells  to 
half  their  normal  number,  with  marked  poikilocytosis.  The  cases  with 
leucocytosis  are  graver  than  those  without. 

Treatment. — It  is  of  the  first  importance  to  treat  the  cause,  as,  for  in- 
stance, cases  which  are  secondary  to  malaria,  syphilis,  or  rhachitis  ;  or  to 
remove  the  cause,  if  possible,  in  cases  of  inhalation  or  ingestion  of  poisons, 
such  as  arsenic,  impure  air,  or  improper  food.  The  general  treatment  in 
infants  and  young  children  is  usually  far  more  important  than  the  use  of 
drugs.  The  treatment  of  infants  is,  above  all,  prophylactic,  with  the  object 
of  protecting  them  from  such  unfavorable  influences  as  may  interfere  with 
their  health  and  proper  development.  The  question  of  feeding  or  of 
adapting  the  food  to  the  child's  digestion  is  of  great  importance,  and 
fresh  air,  in  the  country  if  possible,  is  indicated.  The  best  forms  of  iron 
to  be  used  in  the  secondary  anaemias  of  infants  and  young  children  are 
the  saccharated  carbonate  and  the  tartrate  of  iron  and  potash.  At  times 
arsenic  in  the  form  of  Fowler's  solution  can  be  used. 

The  following  case  of  secondary  anaemia,  occurred  in  a  child  suffer- 
ing from  rhachitis  with  splenic  enlargement,  and  is  represented  in  Fig. 
84,  page  325: 

The  child  was  three  years  old  and  fairly  well  nourished.  It  had,  however,  en- 
larged epiphyses,  a  rhachitic  rosary,  a  square,  rhachitic  head,  and  marked  bowing  of  the 
legs.  On  physical  examination  there  was  no  indication  of  enlargement  of  the  liver  or 
glands.  The  spleen  was  very  much  enlarged,  its  outline  showing  the  notch  as  indi- 
cated in  black.     The  blood  examination  gave  the  following  result : 

Red  corpuscles ■. 2,686,250 

Hiemoglobin ~. 35  per  cent. 

"White  corpuscles 13,000 

There  were  poikilocytosis  and  a  marked  pallor  of  the  corpuscles.      (Wentworth.) 

The  following  is  a  case  of  secondary  anaemia  occurring  in  connection 
with  congenital  syphilis  with  enlarged  spleen,  and  is  represented  in  Fig. 
120,  page  528 : 

The  infant  was  three  months  old,  and  was  nursed  by  its  mother.  It  was  healthy 
at  birth,  and  remained  so  until  three  months  old,  when  it  showed  marked  syphilitic 
symptoms,  vvhich  later  became  very  characteristic.  It  was  faiily  well  nourished.  The 
skin  was  of  the  waxen  pallor  characteristic  of  the  higher  grades  of  grave  anaemia. 
There  was  a  moderate  enlargement  of  the  liver,  which,  on  palpation,  was  found  to  be 
hard  and  somewhat  tender.  The  inguinal  lymph-nodes  were  slightly  enlarged.  The 
post-aural  lymph-nodes  were  enlarged.  The  spleen  was  much  enlarged,  and  extended 
from  the  fifth  rib  to  the  left  inguinal  region.  It  had  a  peculiar  tongue-shaped  outline., 
and  was  hard  but  not  tender.  There  were  no  other  glandular  enlargements.  An  ex- 
amination of  the  blood  gave  the  following  result : 

Nov.  17.  Nov.  20. 

Red  corpuscles 3,387,000  3,300,000 

Hifiinoglobin 47  per  cent.  45  per  cent 

White  corpuscles 20,000  20,000 

There  was  considerable  variation  in  the  size  of  the  red  blood-corpuscles,  which  were 
pale  and  showed  a  moderate  degree  of  poikilocytosis  ;  there  were  also  some  microcytes 


912  PEDIATRICS. 

and  megalocytes.     The  mononuclear  elements  predominated.     The  eosinophiles  were 
not  numerous.     (Wentworth.) 

THE  LYMPH-NODES. 

Pathological  conditions  of  the  lymph-nodes  may  be  primary  or  second- 
an'.  The  j3nman//o/-m.s  are  represented  by  simple  inflammations  of  the 
lymph-nodes  (shnple  acute  adenitis),  caused  by  the  colon  bacillus  and  other 
micro-organisms  from  the  mouth  and  gastro-enteric  tract.  Among  these 
organisms  the  tubercle  bacillus  holds  an  especially  prominent  place. 

The  secondary  forms  are  due  to  tuberculosis,  s^^iDhilis,  and  anaemia,  and 
have  been  considered  under  these  diseases. 

SIMPLE    ACUTE    ADENITIS. 

Etiology. — The  place  of  invasion  of  the  infection  which  produces 
simple  acute  adenitis  is  either  the  skin  or  the  mucous  membranes,  the 
bacteria  or  then-  toxines  reaching  the  nodes  by  means  of  the  lymphatics. 

The  cerviccd  nodes  may  be  infected  from  a  number  of  sources,  such  as 
irritation  or  lesions  of  the  scalp,  the  ears,  eyes,  nose,  throat,  gums,  or 
teeth. 

The  bronchial  nodes  may  be  infected  from  the  trachea,  bronchi,  and 
lung  tissue,  such  as  in  bronchitis  and  in  pneumonia. 

The  mesenteric  nodes  may  be  involved  in  the  course  of  the  various 
infections  of  the  intestines. 

Axillary  adenitis  may  result  from  lesions  of  the  arm,  such  as  are  pro- 
duced by  vaccination ;  and  in  a  like  msniner  inguinal  adenitis  may  follow 
lesions  of  the  foot  and  leg  or  infectious  conditions  of  the  genitals. 

Acute  adenitis  is  also  a  frequent  complication  of  the  acute  mfectious 
diseases,  especially  scarlet  fever,  measles,  and  diphtheria. 

Infection  and  enlargement  of  the  superficial  nodes  demand  special 
consideration,  as  they  are  of  frequent  occurrence  and  are  easily  detected. 
Infection  of  the  deeper  nodes  had  best  be  described  in  connection  with 
the  organs  Avith  which  they  are  especially  connected,  as  their  clinical 
recognition  is  so  often  impossible.  Thus,  when  there  is  an  acute  infec- 
tion of  the  bronchial  or  mesenteric  nodes,  general  symptoms  of  cough 
and  diarrhcea  are  usually  referred  to  the  lung  or  intestine,  unless,  as  may 
occur  in  extreme  cases,  distinct  symptoms  of  pressure  in  the  thorax  or 
palpable  tumors  m  the  abdomen  are  present. 

Pathological  Anatomy. — The  affected  nodes  show  a  condition  of  acute 
congestion  and  hyperplasia,  but  do  not  become  cheesy,  except  when  the 
infection  is  tubercular.  The  process  may  end  in  suppuration  or  resolu- 
tion, according  to  the  severity  of  the  infection.  Suppuration  is  especially 
frequent  in  infants  and  in  young  children,  and  the  pus  usually  begins  in 
the  second  or  third  week  from  the  onset  of  the  morbid  process. 

Periglandular  cellulitis  is  common  when  the  infection  is  acute  and 
severe. 


THE    LYMPH-XODEri    IN ,  INFANCY   AND    CHILDHOOD.  913 

Symptoms. — There  is  very  little  or  no  constitutional  disturbance  in 
non-suppurative  adenitis.  The  nodes  are  enlarged,  hard,  and  tender,  and 
if  periadenitis  is  present,  immovable.  Lymphangitis  and  fever  may  be 
present.     The  swelling  usually  subsides  slowly  after  a  few  months. 

In  the  suppurative  cases  there  may  be  quite  severe  general  as  well  as 
local  disturbance,  with  fever  and  chills.  The  nodes,  if  opened,  usually 
heal  quickly  and  completely. 

Diagnosis. — The  diagnosis  of  simple  acute  adenitis  of  the  superficial 
lymph-nodes  is  not  difficult,  if  some  local  condition  can  be  found  to  ac- 
count for  it.  The  differential  diagnosis  from  tubercular  adenitis  is  de- 
scribed under  tubercular  lymph-nodes,  on  page  385. 

Treatment. — The  first  effort  in  undertaking  the  treatment  of  these 
cases  should  be  to  seek  for  and  remove  the  peripheral  source  of  irritation 
w^hich  exists  in  most  cases.  Decayed  teeth  should  be  extracted,  eczema 
of  the  scalp  should  be  treated,  and  in  all  cases  as  much  as  possible  should 
be  done  to  diminish  any  irritation  m  the  area  of  surface  drained  by  the 
cervical  lymphatics.  During  the  active  stage  of  cervical  adenitis  it  is 
better  not  to  make  any  application  to  the  glands,  but  to  treat  any  general 
distiu-bances,  such  as  anasmia  or  debility,  which  may  be  present. 

If  the  glands  suppurate,  they  should  be  freely  opened,  when  the  pus 
has  pointed,  and  be  treated  A\'ith  antiseptics.  If  there  is  much  broken- 
down  tissue,  the  abscess  cavity  should  be  curetted. 

SIMPLE    CHRONIC    ADENITIS. 

In  cases  of  simple  chronic  adenitis  the  enlargement  of  the  nodes  is 
due  to  a  simple  hyperplasia.  Both  the  superficial  and  deep  nodes  may 
be  affected,  but  for  the  same  reason  stated  in  speaking  of  acute  adenitis, 
the  affections  of  the  superficial  nodes  only  will  be  spoken  of  here. 

Chronic  adenitis  is  much  less  common  than  acute  adenitis,  and  rarely 
occurs  except  in  infants  and  young  children.  It  usually  occm-s  as  a  re- 
sult of  several  attacks  of  acute  inflammations  or  of  chronic  affections  of 
the  skin  or  mucous  membranes.  The  nodes  are  usually  more  uniformly 
enlarged,  but  the  swelling  is  not  so  great  as  in  either  the  acute  or  tuber- 
cular forms.  There  is  no  constitutional  disturbance  referable  to  the  nodes 
themselves.  The  course  is  slow,  and  may  extend  over  a  period  of  months 
or  years.  There  may  be  an  associated  h)-pertrophy  of  lymphoid  tissue 
elsewhere,  as  in  that  of  the  tonsils  and  in  adenoids. 

Dlvgnosis. — From  Tubercular  Adenitis. — Simple  chronic  adenitis  is 
most  frequently  confounded  with  tuberculosis.  The  chief  points  in  the 
differential  diagnosis  are  found  in  its  usual  occurrence  in  very  young  chil- 
dren at  an  age  when  glandular  tuberculosis  is  uncommon,  in  the  evidence 
of  a  primarj^  cause  to  which  the  chronic  adenitis  is  secondary,  in  the  ab- 
sence of  caseation,  suppuration,  and  periadenitis,  and,  finally,  in  the 
greater  influence  of  general  tonic  treatment. 

From  Hodghins  Disease. — Simple  chronic  adenitis  is  distinguished  less 

58 


914 


PEDIATPlICS. 


Fig.  186. 


easily  from  Hodgkin's  disease,  but  in  the  latter  the  enlargement  of  the 
nodes  is  greater  and  more  generally  distributed,  the  secondarj'  anaemia  is 
more  pronounced,  and  the  disease  is  of  rare  occurrence  as  compared  with 
chronic  adenitis. 

From  SyjMUtic  Adenitis. — The  absence  of  other  signs  of  late  syphilis, 
such  as  are  described  on  page  529,  and  the  negative  results  of  anti-syphi- 
litic treatment  make  the  exclusion  of  syphilitic  adenitis  comparatively 
easy. 

From  Kew  Grotdhs. — Xew  gro^\ihs  are  usually  to  be  distinguished  by 
their  greater  size  and  by  the  absence 
of  an  exciting  cause,  more  positively 
by  the  microscopic  examuiation  of  a 
portion  of  the  node  excised  for  the 
purpose  of  diagnosis. 

Treatment. — In  the  treatment  of 
simple  chronic  adenitis,  the  primary 
exciting  cause  should  be  removed  if 
possible.  Local  applications  should 
be  avoided,  and  general  tonic  treat- 
ment mstituted  by  means  of  cod-liver 
oil.  Fowler's  solution,  the  iodide  of 
iron,  good  food,  and  out-of-door  life. 
If  these  measures  fail,  the  treatment 
becomes  surgical. 

Fig.  186  represents  a  case  of 
cln'onic  cervical  adenitis  in  wliich  the 
cervical  lymph-nodes  were  enlarged  to 

such  an  extent  that  they  had  become  a  deformity.  Nothing  else  abnormal 
nor  any  symptom  of  tuberculosis  Avas  discovered  about  the  child. 

DISEASES  OF  THE  THYROID  GLAND. 
The  function  of  the  thyroid  gland  is  not  definitely  known,  but  it  is 
generally  believed  to  secrete  certain  nutritive  or  antitoxic  substances 
which  are  necessary  for  normal  metabolism.  Disturbance  in  the  func- 
tion of  the  gland,  resulting  either  in  h\-persecretion  or  diminished  secre- 
tion, gives  rise  to  different  types  of  symptoms.  Such  disturbances  may 
be  produced  by  simple  hyperemia,  hypertrophy,  atrophy,  new  gro^^ihs,  or 
as  a  result  of  excision  of  the  gland. 

GOITRE  (Bronchocele). 
Enlargement  of  the  thyroid  gland  is  commonly  called  goitre.  True 
goitre  consists  in  the  enlargement  of  the  old  and  hi  the  formation  of  new 
alveoli,  m  the  cells  of  which  a  greater  or  less  amount  of  colloid  degenera- 
tion takes  place.  The  colloid  abnormalities  of  goitre  are  rarely  present 
in  children  (Rex),  in  whom  the  thyroid  enlai^ement  seems  to  be  little 


A 


Chronic  cervical  adenitis. 


THE    DUCTLESS    GLANDS    IN    INFANCY   AND    CHILDHOOD. 


915 


Fig.  187. 


more  than  a  continuation  of  the  natural  growth  and  a  true  hypertrophy 
or  an  excessive  development  of  normal  tissue.  Usually  the  enlargement 
of  the  gland  is  the  only  symptom.  '  Infants  have  been  born  with  an  en- 
larged th}Toid. 

The  disease  is  endemic  in  Switzerland,  in  certain  parts  of  France  and 
Italy,  and  in  Michigan.  The  enlargement  may  be  purely  vascular  (hyper- 
£emia  of  the  thyroid),  parenchymatous,  or  cystic.  In  places  in  which  the 
disease  is  endemic  the  cause  in  many  cases  seems  to  be  due  to  the 
drinkmg-water.  It  has  a  certain  relation  to  the  congenital  form  of  myxoe- 
dema,  or  cretinism,  the  nature  of  which  has  not  been  fully  determined. 
A  woman  with  goitre  may,  on  removal  to  a  place  in  which  the  disease  is 
endemic,  give  birth  to  a  cretin.  '  Although  a  simple  goitre  generally  gives 
rise  to  no  symptoms  other  than  those  of  pressure,  symptoms  of  myx- 
oedema  may  develop.  The  inference  is  that  this  complication  is  due  to 
the  interference  with  the  function  of  the  gland,  as  a  result  of  which  its 
secretions  are  either  diminished  or  entirely  checked.  When  myxoedema 
does  not  develop,  as  it  does  not  in  the  majority  of  cases  of  goitre,  we 
may  account  for  the  fact  on  the  supposition  that  the  enlargement  of  the 
gland  has  not  affected  its  function  as  a  secreting  organ. 

Hypersemia  of  the  Thyroid. — 
Between  the  ages  of  twelve  and  fifteen 
years  in  girls,  about  at  the  time  of 
puberty,  an  active  hypergemia  of  the 
rich  vascular  tissue  of  the  thyroid  oc- 
curs, leading  at  times  to  a  consider- 
alDle  and  rapid  enlargement  of  the 
gland.  Angemia,  especially  chlorosis, 
palpitation,  accelerated  pulse,  and 
various  nervous  symptoms  are  not 
uncommon  at  this  same  period,  and 
when  noted  in  connection  with  the 
liypersemia  and  enlargement  of  the 
thyroid  may  give  rise  to  the  belief 
that  the  condition  is  the  beginning  of 
the  much  more  serious  disease  ex- 
ophthalmic goitre.  This  enlargement 
of  the  thyroid  does  not  usually  persist, 
however,  the  disease  generally  subsiding  under  appropriate  treatment  of 
the  anaemia  and  galvanization  of  the  thyroid,  and  the  diagnosis  is  readily 

made. 

Fig.  187  represents  one  of  these  physiological  disturbances  in  the 
thyroid  due  to  an  active  hyperaemia. 


Hypersemia  of  the  thjToid  gland.     Female, 
13  years  old. 


The  girl,  thirteen  years  old,  was  first  noticed  to  have  a  swelling  of  the  thyroid  gland 
two  or  three  weeks  before  coming  under  observation.     The  swelling  was  at  that  time 


916  pediatrics: 

becoming  more  prominent.  The  catamenia  had  not  appeared.  The  girl  was  well 
and  strong,  but  was  more  fretful  and  capricious  than  seemed  consistent  with  her  usual 
temperament.    The  tumor  was  elastic,  did  not  fluctuate,  and  was  neither  red  nor  tender. 

MYXCEDEMA. 

Myxoedema  is  a  constitutional  affection,  g-enerally  associated  with 
atrophy  of  the  thyroid  gland,  and  characterized  clinically  by  a  thickened 
and  dry  condition  of  the  skin  and  subcutaneous  tissues,  and  later  by 
mental  failure. 

The  symptoms  are  supposed  to  be  caused  by  a  diminished  or  total  lack 
of  secretion  of  the  th>Toid  gland  due  to  its  atropine  condition  {athyrea). 
The  disease  may  be  congenital  or  acquired.  Acquired  myxoedema  is  seen 
most  commonly  in  adults,  and  will  not  be  especially  described.  Operative 
myxoedema.  or  cachexia  strumipriva,  is  a  condition  closely  resembling  ac- 
quired myxoedema  of  adults,  and  follows  the  removal  of  the  thjToid  gland 
by  operation.  The  form  of  myxoedema  which  is  especially  related  to  in- 
fants and  children  is  that  which  is  known  as  cretinism,  or  congenital 
myxoedema. 

Cretinism  [congenital  myxoedema). — Two  classes  of  cases  are  recog- 
nized:  one,  kno\vn  as  endemic  cretinism,  represented  by  the  cretins  of 
S^\1tzerland,  Italy,  France,  of  the  great  lakes  (Michigan)  of  America,  and 
of  other  places ;  and  a  second  class,  known  as  sporadic  cretinism,  repre- 
sented by  individual  cases  which  maybe  met  with  anywhere. 

Pathological  Axatomt. — There  may  be  a  congenital  absence  of  the 
thyroid  gland,  or  atrophy  may  occur,  as  after  one  of  the  specific  infectious 
diseases. 

The  head  in  sporadic  cretuiism  is  usually  brachycephalic, — that  is,  it  is 
contracted  in  its  antero-posterior  diameter.  Virchow  was  the  first  to  observe 
in  these  cases  a  premature  ossification  of  the  spheno-basilar  bone.  The 
sphenoid  and  basi-occipital  bones  should  remain  separate  until  about  the 
fifteenth  year,  and  their  early  ossification  explains,  according  to  Virchow, 
the  changes  which  take  place  in  the  form  of  the  cretin  skull  and  face. 

Occasionally  the  thyroid  gland  in  a  cretin  is  enlarged,  as  in  a  simple 
goitre,  but  its  function  is  absent,  as  shown  by  the  symptoms  characteristic 
of  athyrea. 

There  are  certain  characteristics  of  the  bones  in  cretins,  consisting  of 
an  enormous  overgrowth  of  cartilage,  an  arrest  of  growth  at  the  distal 
ends  of  the  bones,  and  a  premature  ossification  of  the  shaft.  Fig.  79.  II.. 
page  316,  represents  a  section  of  the  tibia  of  a  sporadic  cretin  child.  It 
is  distinguished  anatomically  by  an  almost  entire  absence  of  the  zone  of 
proliferation  (^Miitney). 

Symptoms. — In  sporadic  cretmism  the  symptoms  of  the  disease  usually 
develop  in  the  first  year  of  life,  sometimes  not  until  the  second  or  tliird 
year  or  even  later.  The  body  is  dwarfed.  The  anterior  fontanelle  re- 
mains open  until  the  eighth  or  tenth  year.  The  face  is  full,  stolid,  and 
expressionless.    The  nose  is  broad  and  flat ;   the  eyes  are  small,  wide 


THE   DUCTLESS   GLANDS   IN   INFANCY   AND   CHILDHOOD.  917 

apart  and  half  closed  by  the  swollen  lids.  The  mouth  is  open,  the  lips 
are  thick,  and  the  tongue  protrudes.  The  cheeks  are  swollen  and  bloated. 
The  hair  is  coarse  and  straight,  and  usually  light-colored.  The  teeth  are 
rough,  irregular,  and  liable  to  early  decay.  The  voice  is  rough  and  harsh. 
Spinal  curvature  is  apt  to  be  present,  and  is  much  more  likely  to  be  in  the 
nature  of  a  lordosis  than  of  a  kyphosis.  The  extremities  are  short  and 
stunted,  and  the  hands  and  feet  are  pudgy.  Normally  at  birth  the  legs 
are  about  43  per  cent,  of  the  total  height,  and  at  four  or  five  years  about 
50  per  cent.  In  cretins  this  percentage  is  lessened  to  between  35  and 
40  per  cent,  of  the  total  length.  The  skin  is  everywhere  dry,  thick,  and 
bloated,   and   does   not  pit   on   pressure.     Perspiration  is  scanty.     The 

Fig.   188. 


Sporadic  cretinism  in  an  infant  10  months  old,  terminating  in  sudden  death. 


muscles  are  weak  and  flabby,  and  the  motions  slow  and  clumsy.  The 
neck  is  short  and  thick,  and  the  abdomen  large  and  pendulous.  Fatty 
tumors  are  not  infrequently  to  be  found  in  the  supra-clavicular  regions. 
The  genitals  are  small  and  undeveloped.  Habitual  constipation  is  com- 
mon. The  temperature  is  frequently  subnormal.  The  temperament  of 
cretins  is  placid,  and  their  expression  stupid  or  even  idiotic.  Their  mental 
and  physical  development  is  very  backward ;  they  learn  to  talk  late  or  not 

at  all. 

Diagnosis. — The  appearance  of  a  cretin  is  so  characteristic  that  a  diag- 
nosis is  rarely  difficult.  Foetal  or  early  and  severe  rhachitis  may  give  rise 
to  marked  deformities  suggestive  of  cretinism,  but  do  not  show  the  other 
physical  signs  and  the  mental  symptoms. 


918 


PEDIATRICS. 


Treatment. — The  recognized  specific  treatment  of  all  forms  of  myxoe- 
dema  is  the  administration  of  preparations  of  the  thyroid  gland.  The 
success  of  this  method  is  one  of  the  most  brilliant  triumphs  of  modern 
experimental  medicine.  The  results  of  treatment  for  several  months  are 
remarkable,  as  the  entire  appearance  of  the  child  is  changed.  The  thick- 
ening of  the  skin  disappears,  the  idiotic  expression  is  lost,  and  the  growth 
and  development  of  both  body  and  mind  progress  rapidly.  A  large  num- 
ber of  cases  have  been  reported  illustrating  the  effects  of  the  thyroid  treat- 
ment. The  question  whether  the  improvement  will  continue  indefinitely 
and  go  on  to  complete  and  permanent  recovery  is  one  for  the  future  to 
decide. 

The  dried  powdered  gland  or  the  glycerin  extract  are  the  most  conve- 
nient means  of  administration. 

The  dried  thyroid  extract  may  be  given  in  tablet  form  in  doses  of  0.03 
to  0.06  gramme  {I  to  1  grain)  three  times  daily.     Unpleasant  effects  from 

the  treatment  are  rare.  A  decided  rise 
in  the  temperature  indicates  that  the 
use  of  the  thyroid  extract  should  be 
suspended  for  a  time.  The  earlier  the 
treatment  is  begun  the  better  are  the 
results  obtained.  When  the  normal 
condition  of  the  body  has  been  restored 
by  the  use  of  fairly  large  doses  of  the 
thyroid  extract,  it  will  be  necessary  to 
continue  the  treatment  indefinitely  with 
doses  small  enough  to  maintain  the 
equilibrium  of  the  metaJDolism  of  the 
body.  It  should  be  remembered  that 
these  children  are  especially  susceptible 
to  cold,  and  should  be  kept  in  an  even 
temperature  or  taken  to  a  warm  climate 
during  the  winter. 

Fig.   L89  represents  a  case  of  spo- 
radic cretinism. 

The  child  -was  a  girl,  five  and  a  half  years 
old.  Her  parenis  were  healthy  Americans,  not 
blood  relations,  and  did  not  have  goitre.  She 
was  born  after  a  severe  labor  ;  it  was  a  head 
presentation,  and  no  instruments  were  used. 
Nothing  especially  abnormal  was  noticed  about 
her  until  the  twelfth  month,  when  she  did 
not  seem  so  bright  as  is  usual  at  that  age. 
When  four  years  old  she  was  brought  to  the  hospital.  She  could  not  speak,  and  her 
mental  condition  was  much  enfeebled.  She  could  scarcely  stand,  and  looked  as  though 
she  were  about  one  and  a  half  years  old.  She  had  never  had  any  convulsions,  but  had 
always  had  incontinence  of  urine  and  of  faeces.     When  seen  a  year  later  she  appeared 


MyxcEdema.    P^emale,  b}4  years  old. 


THE   DUCTLESS   GLANDS   m  LNFANCY   AND   CHILDHOOD. 


919 


to  be  in  good  general  condition,  bat  her  muscles  were  large  and  flabby,  and  she  had  not 
improved  mentally.  The  circumference  of  her  head  was  46.05  cm.  (18^  inches).  The 
measurement  from  the  occiput  to  the  root  of  the  nose  was  34.4  cm.  (13 J  inches),  and 
across  the  head  from  external  meatus  to  external  meatus  29.3  cm.  (11^  inches). 
The  circumference  of  the  thorax  was  40.3  cm.  (lof  inches).  There  were  no  irregulari- 
ties about  her  head.  The  forehead  was  overhanging,  and  this  was  rendered  more  strik- 
ing on  account  of  the  sunken  bridge  of  the  nose.  The  lips  were  thick,  and  the  tongue, 
which  seemed  enlarged,  was  protruded  between  them.  The  hearing  was  said  to  be  good, 
and  the  sight  was  good.  She  had  been  able  to  sit  alone  since  she  was  one  year  old,  but 
could  stand  only  with  support,  and  could  not  walk.  She  was  bow-legged,  and  the  bones 
were  somewhat  enlarged  about  the  epiphyses.  The  hands  and  feet  were  large  and 
puffy,  but  did  not  pit.  The  feet  were  bright  red,  the  hands  less  so.  The  trunk  was 
stout  and  thick  ;  the  spine  was  straight ;  the  lungs  and  heart  were  normal,  and  nothing 
abnormal  could  be  detected  about  the  abdomen  except  an  umbilical  hernia.  The  ten- 
don reflexes  were  normal.  Sensation  was  normal.  The  thyroid  gland  could  not  be 
felt.  The  teeth  were  good.  There  was  a  general  condition  of  infiltration  of  the  skin 
like  myxcedema.  Hebetude  was  marked.  The  treatment  of  this  child  Avas  with  an  ex- 
tract made  from  the  thyroid  gland  of  a  sheep,  0.06  c.c.  (1  minim)  of  the  thyroid  extract 
being  given  three  times  daily,  which  was 
gradually  increased  1  minim  every  two 
days  unless  the  rectal  temperature  rose 
above  37.7°  C.  100°  F.).  There  was  a 
slight  improvement  of  the  symptoms  be- 
fore the  child  left  the  hospital,  but  her 
parents  did  not  return  with  her  to  report 
the  subsequent  progress  of  the  disease. 

Fig.  190  represents  a  case  of 
sporadic  cretinism  Avhich  occurred 
in  the  practice  of  Northrup,  of  New 
York,  who  describes  it  as  follows : 


"The  parents  of  the  child  were 
healthy  Americans  from  Western  Penn- 
sylvania, and  they  were  not  consanguine- 
ous. The  father  was  forty-five  years  old  ; 
the  mother  was  thirty-nine  years  of  age, 
had  had  several  miscarriages  and  four 
healthy  children,  two  of  whom  had  died 
of  some  acute  disease.  This  little  girl, 
Avho  is  now  nine  years  old,  is  the  fifth 
child.  The  mother  first  noticed  that  the 
child  could  not  sit  up  when  it  was  nine 

months  old,    that  it  practically   ceased  to        Myxcedema.   Female,  9  years  old.  Slight  improve- 
o-row,  and  now  at  nine  years  it  is  men-    ment  after  eighty  days'  treatment  with  thyroid 
tally  no  older  than  it  was  at  nine  months,    extract, 
and  physically  it  has  merely  thickened. 

The  first  impression  one  gets  on  looking  at  the  child  is  that  it  is  an  idiot.  Its  hands  are 
large  and  broad.  Its  color  is  peculiarly  sallow.  The  hair  is  thin,  long,  dry,  and  with- 
out lustre.  The  eyebrows  are  present,  and  are  not  remarkable  in  any  way.  She  has 
the  characteristic  flattening  of  the  bridge  of  the  nose,  diffuse  swelling  of  the  under  lid 
and  puffiness  of  the  upper  lid,  and  pendulous  cheeks.     She  has  thick,  pale  lips,  with  a 


920  PEDIATRICS. 

protuding  tongue,  which  is  swollen  and  pale.  The  lips  and  tongue  have  a  tendency 
to  dryness.  There  are  fourteen  teeth  ;  all  of  them  are  of  the  first  set.  Those  in  the 
upper  row  are  eroded,  and  appear  only  at  the  bottom  of  a  series  of  ulcers  in  the  upper 
gums.  The  lower  teeth  are  in  nearly  the  same  condition,  and  the  gums  are  suppura- 
ting. An  offensive  odor  is  always  present  in  the  mouth.  The  arms,  legs,  feet,  and 
hands  are  unnaturally  thick.  The  abdomen  is  prominent,  and  there  is,  as  is  seen,  an 
umbilical  hernia.  The  hand  which  is  resting  on  its  mother's  black  glove  shows  the 
dry,  wrinkled  condition  so  characteristic  of  myxoedema.  Perspiration  is  absent.  The 
skin  is  pale,  and  has  a  peculiar  mottled  appearance.  The  soles  of  the  feet  and  the 
palms  of  the  hands  are  dry.  There  is  marked  lordosis.  The  surface  of  the  child 
does  not  suggest  the  feeling  of  oedema,  nor  does  it  pit.  The  feeling  is  that  of  pufBness 
and  flabbiness.  The  child  cannot  sit  alone.  It  can,  however,  stand  when  once  bal- 
anced and  allowed  to  grasp  some  fixed  object.  The  supraclavicular  '  pad'  of  tissue  so 
commonly  found  in  these  cases  is  present.  The  thyroid  gland  seems  to  be  present,  and 
is  possibly  enlarged.  Hebetude  is  shown  to  a  marked  degree,  and  the  delayed  cere- 
bration is  very  evident,  although  the  child  never  speaks  except  to  say,  with  infinite 
slowness,  *  da — da.' 

"The  rectal  temperature  four  days  before  treatment  was  begun  was  3G.4°  C. 
(97.5°  F.)  in  the  morning,  and  37.5  C.  (99.5°  F.)  in  the  evening.  The  child  was 
treated  with  the  thyroid  extract  prepared  so  that  each  drachm  represented  one  thyroid 
gland  of  a  yearling.  Of  this  preparation  0.06  c.c.  (1  minim)  was  given  three  times  a 
day  until  the  fourth  day,  when  the  temperature  rose  above  37.7°  C.  (100  F.),  and  the 
treatment  was  stopped  for  a  day.  At  this  time  the  appetite  had  improved,  and  the 
breath  was  not  so  offensive.  Two  days  later  the  treatment  was  begun  again,  and  on  the 
eighth  day  the  tongue  was  found  to  be  considerably  smaller.  During  the  next  week  the 
temperature  remained  under  37.7°  C.  (100°  F.).  It  then  rose  above  37.7°  C. 
(100°  F.),  and  the  treatment  was  suspended.  The  first  tooth,  a  canine,  was  cut  at  this  time. 
The  largest  dose  which  was  given  during  the  treatment  was  0.24  c.c.  (4  minims)  three 
times  a  day.  The  child  was  treated  eighty  days  in  this  way.  The  improvement  was  very 
slight,  but  the  countenance  was  brighter,  the  tongue  became  much  smaller,  and  the  skin 
less  dry.  She  lost  somewhat  in  weight  while  under  treatment.  The  constipation,  which 
was  marked  when  the  treatment  was  begun,  disappeared,  and  she  was  willing  to  take  a 
much  greater  variety  of  food."" 

The  next  case  represents  one  of  sporadic  cretinism  which  came  under 
/^    the  obsers-ation  of  Osier,  of  Baltimore,  when  she  was  four  years  old. 

The  parents  were  healthy,  and  there  was  no  hereditary  taint  on  either  side  of  the 
family,  none  of  whom  had  had  goitre.  She  was  the  second  child  ;  the  labor  was  easy, 
and  she  throve  well.  She  had  never  had  any  diseases.  Nothing  especial  was  noticed 
about  the  child  until  its  second  year,  when  it  was  obser\^ed  that  she  did  not  attempt  to 
walk  or  talk,  and  that  she  seemed  unnaturally  quiet  and  dull.  She  did  not  cut  her  first 
teeth  until  she  was  two  years  old.  In  her  third  year  her  skin  became  very  pale  and 
waxy,  and  her  face  and  limbs  seemed  puffy  and  swollen.  She  had  developed  very 
little  mentally,  and  could  say  only  one  or  two  words.  The  other  symptoms  indica- 
tive of  a  disturbance  of  the  function  of  the  thyroid  gland  gradually  appeared,  such  as 
the  myxcedematous  condition  of  the  subcutaneous  tissues  and  the  development  of 
the  supraclavicular  pad.  The  thyroid  gland  could  not  be  felt.  The  examination  of  the 
blood  showed  a  moderate  increase  of  leucocytes  and  some  irregularity  in  the  size  of  the 
erythrocytes.  When  three  and  a  half  years  old  she  was  75  cm.  (29f  inches)  tall,  and 
her  head  measured  52.3  cm.  (20  J  inches).  She  had  been  under  treatment  with  tonics 
for  a  year,  and  was  reported  to  take  more  notice  and  to  look  more  intelligent.  She 
was  then  treated  with  the  thyroid  extract,  and  improved  markedly  in  both  her  mental 


THE   DUCTLESS   GLANDS   IN  INFANCY   AND   CHILDHOOD.  921 

and   her   physical    condition.     The    tongue,   whicli  had  been   thick   and   protruding, 
rapidly  became  smaller,  and  she  began  to  walk  and  talk. 

EXOPHTHALMIC  GOITRB. 

Exophthalmic  goitre  occasionally,  but  rarely,  occurs  in  childhood,  in- 
dependent of  the  physiological  disturbance  which  has  been  described 
under  hypersemia  of  the  thyroid  gland  on  page  915, 

Etiology. — According  to  Sachs,  heredity  plays  a  much  more  important 
part  in  children  in  the  production  of  the  disease  than  the  emotional  ex- 
citement, fright,  cardiac  disease,  and  severe  constitutional  disorders  which 
so  frequently  underlie  the  condition  in  adults.  Epilepsy,  chorea,  and 
chronic  alcoholism  in  the  parents  predispose  to  the  development  of  the 
disease  in  children. 

Exophthalmic  goitre  is  considered  by  some  writers  to  be  due  to  a 
pure  neurosis,  by  others  to  central  lesions  in  the  medulla  oblongata.  The 
more  recent  views  attribute  it  to  hypersecretion  of  the  thyroid  gland,  to 
which  the  name  hyperthyrea  is  given,  as  opposed  to  the  athyrea  of  myxoe- 
dema,  in  which  the  symptoms  are  supposed  to  be  due  to  deficient  secre- 
tion. 

Symptoms. — In  some  cases  the  onset  is  acute,  in  others  subacute  or 
chronic,  and  is  characterized  by  the  cardinal  symptoms  of  tachycardia, 
exophthalmos,  muscular  tremors,  enlargement  of  the  thyroid,  and  by 
general  symptoms  of  anaemia,  indigestion  with  a  special  tendency  to  pro- 
fuse diarrhgea,  slight  fever,  loss  of  weight,  and  many  other  symptoms  of  a 
neurasthenic  character. 

Tachycardia. — ^The  pulse-rate  is  increased  to  90,  100,  120,  or  even 
200  per  minute,  the  rate  being  increased  in  states  of  excitement  and  low- 
ered when  mental  and  physical  rest  is  enforced.  There  is  no  evidence  of 
an  organic  lesion  in  the  heart.  All  the  arteries  throughout  the  body 
pulsate  with  unusual  distinctness.  Owing  to  the  increased  blood-tension, 
hemorrhages  may  occur  from  the  nose,  stomach,  or  intestines.  Upon 
palpation  of  the  goitre  a  distinct  thrill  may  be  felt. 

Exophthalmos. — The  protrusion  of  the  eyeball  is  not  accompanied  by 
disturbance  in  vision.  Limitation  of  the  field  of  vision  with  ulceration 
of  the  cornea  from  want  of  protection  of  the  lids  may  occur.  Graefe's 
symptom,  a  failure  of  the  upper  lid  to  follow  promptly  a  downward  move- 
ment of  the  bulb,  Stellwag's  symptoms  of  a  dilated  palpebral  fissure,  and 
Moebius's  symptom  of  defective  convergence  of  the  axes  of  the  two  eyes 
are  signs  to  be  noted  in  connection  mth  the  exophthalmos,  but  are  not 
always  present. 

Thyroid  Enlargement. — The  thyroid  is  almost  always  enlarg-ed,  but  the 
increased  size  may  follow  rather  than  precede  the  other  cardinal  symp- 
toms. The  enlargement  is  usually  bilateral  and  symmetrical,  the  tissues 
are  vascular,  hyperplastic,  and  may  show  fibrinous  degeneration. 

Muscular  Tremors. — The  muscular  tremors  are  usually  rhythmical,  and 
at  the  rate  of  about  eight  to  the  second. 


922  PEDIATRICS. 

Throbbing  of  the  blood-vessels  and  free  perspiration  are  unpleasant 
symptoms,  adding  to  the  discomfort  and  nervousness  of  the  patient.  In- 
tense pigmentation  of  the  skin,  resembling  Addison's  disease,  may  rarely 
occur,  or  areas  of  leucoderma,  or  of  urticaria.  Very  rarely  myxoedema  has 
developed  towards  the  end  of  the  disease.  Marked  diminution  in  the 
electrical  resistance  is  present,  and  may  be  due  to  the  profuse  sweating. 
Glycosuria  and  albuminuria  are  occasional  complications. 

Diagnosis. — The  diagnosis  is  made  by  the  recognition  of  the  cardinal 
symptoms.  Physiological  hypersemia  of  the  thyroid  at  puberty  should 
not  be  diagnosticated  as  exophthalmic  goitre. 

Prognosis. — The  course  is  generally  chronic  and  of  several  years' 
duration.  Some  cases  recover,  but  if  the  disease  is  once  well  developed  it 
is  apt  to  be  prolonged,  death  often  ensuing  from  some  intercurrent  affection. 

Treatment. — x4bsolute  rest  in  bed,  avoidance  of  all  excitement,  and 
careful  regulation  of  the  diet  are  essential.  Digitalis  and  strophanthus  are 
sometimes  useful.  Good  results  have  been  reported  from  the  use  of 
belladonna  and  of  atropine.  The  galvanic  current  is  also  recommended. 
The  thyroid  extract  has  proved  of  no  value  in  these  cases.  When  the 
gland  is  so  large  as  to  cause  symptoms  of  pressure,  partial  extirpation  is 
to  be  considered.  The  operation  has  been  done  in  adults  with  good 
results  in  a  certain  number  of  cases. 

Recently  subcutaneous  injection  of  thyroidectomized  goat  lymph  has 
been  tried,  and  in  some  cases  with  success.  We  have  had  one  such  case 
in  our  own  practice. 

ACUTE    THYROIDITIS. 

Acute  inflammation  of  the  thyroid  is  not  very  common,  but  may 
occur  from  a  variety  of  causes.  It  may  result  in  the  formation  of 
abscesses  of  various  sizes  or  in  the  production  of  new  connective  tissue. 
Acute  thyroiditis  is  rarely  primary,  being  commonly  a  metastatic  affection 
-occurring  in  the  course  of  some  febrile  disorder.  It  has  been  noticed 
among  children  as  a  complication  of  measles,  typhoid  fever,  diphtheria, 
and  parotitis,  and  the  process  in  a  majority  of  these  recorded  cases,  in- 
stead of  retrograding  spontaneously  as  it  did  in  others,  caused  an  inflam- 
matory condition  in  which  abscess-formation  occurred.  On  opening  the 
abscesses  the  pus  was  found  to  contain  numerous  micrococci. 

Symptoms. — The  symptoms  of  acute  thyroiditis  are  swelling,  redness, 
and  tenderness  of  the  gland.  Symptoms  of  pressure,  such  as  dyspnoea, 
hoarseness,  painful  deglutition,  and  neuralgic  pains,  are  sometimes  present 
with  fever  and  general  malaise.  The  duration  of  the  disease  is  from  two 
to  three  weeks. 

Treatment. — The  treatment  is  essentially  expectant,  but  some  previ- 
ously intractable  cases  seem  to  have  been  benefited  by  the  application  of 
iodine.  The  patient  should  be  carefully  watched,  and,  if  there  are  indi- 
cations that  suppuration  has  taken  place,  an  incision  should  be  made  at 
once,  as  recovery  then  usually  occurs  quite  cjuickly. 


THE   DUCTLESS   GLANDS   IN   INFANCY   AND   CHILDHOOD.  923 

TUMORS    OF    THE    THYROID    GLAND. 
Malignant  growths  are  extremely  rare  in  the  thyroid.     Gummata  have 
been  found  in  a  certain  number  of  cases  of  congenital  syphilis  and  miliary 
tubercles  in  connection  with  general  miliary  tuberculosis. 

DISEASES  OF  THE  THYMUS  GLAND. 

The  thymus  gland  may  persist  after  the  sixteenth,  and  even  after  the 
twentieth  year,  without  especial  pathological  significance. 

A  considerable  number  of  cases  of  what  is  termed  thymiG  asthma  has 
been  reported. 

In  this  condition  infants  and  young  children,  many  of  whom  were 
supposed  to  be  healthy,  have  had  severe  and  often  rapidly  fatal  attacks 
of  dyspnoea,  which  at  the  autopsy  have  been  found  to  be  dependent  upon 
great  enlargement  of  the  thymus  gland.  Death  in  these  cases  is  supposed 
to  have  been  due  to  pressure  of  the  gland  upon  the  trachea,  upon  the 
great  vessels,  or  upon  the  pneumogastric  nerve,  causing  spasm  of  the 
glottis.     Many  of  these  cases  have  occurred  in  children  with  rhachitis. 

Minute  multiple  hemorrhages  are  not  infrequently  found  in  the  thymus 
giand  in  new-born  infants  who  have  died  of  asphyxia. 

VYmvdiVY  inflammation  of  the  thymus  gland  has  been  reported,  but  is 
extremely  rare.  '- 

Multiple  abscesses  of  the  thymus  gland  have  been  reported  by  Dubois 
in  a  number  of  cases  of  congenital  syphilis.  Chiari  believes  that  these 
supposed  abscesses  were  necrotic  areas  or  cysts.      Gummata  are  rare. 

Tuberculosis  is  rare,  but  when  it  occurs  it  is  usually  either  one  of  the 
lesions  of  a  general  miliary  tuberculosis  or  it  is  secondary  to  a  tubercular 
pneumonia.  The  gland  may  be  enlarged,  but  rarely,  in  leukwmiu,  sarcoma, 
cancer,  and  myo-lipoma. 

According  to  Reich,  the  absolute  dulness  of  the  thymus,  as  determined 
by  light  percussion,  is  irregularly  triangular  in  outline,  the  base  being 
made  by  the  line  connecting  the  two  sterno-clavicular  articulations,  the 
blunt  apex  situated  at  the  level  of  the  second  rib  or  slightly  below  it,  and 
the  sides  a  little  beyond  the  edges  of  the  sternum.  The  larger  half  of 
this  triangle  of  dulness  usually  falls  to  the  left  side.  When  the  limits  of 
dulness,  as  given  above,  vary  by  one  or  more  centimetres,  or  obscure 
the  pulmonary  resonance  between  the  upper  line  of  cardiac  dulness  and 
the  lower  lateral  limits  of  thymus  dulness,  an  enlargement  of  the  thymus 
is  probable.  The  thymus  dulness  is  present  until  the  end  of  the  fifth 
year,  after  which  it  is  inconstant. 

Diagnosis. — The  diagnosis  of  diseases  of  the  thymus  gland  is  very  diffi- 
cult and  generally  impossible.  Symptoms  of  dyspnoea  and  pressure  upon 
the  pneumogastric  nerve,  without  any  other  appreciable  cause,  associated 
with  an  enlargement  of  the  area  of  thymus  dulness  as  just  described, 
render  the  diagnosis  of  some  affection  of  the  thymus  probable.     Reich 


924  PEDIATRICS. 

states  that  s^yollen  lymph-nodes  in  the  anterior  mediastinum  do  not  cause 
dulness,  but  that  cheesy  lymph-nodes  do. 

Treatment. — There  is  no  treatment  other  than  the  control  of  symp- 
toms by  appropriate  means. 

DISEASES  OF  THE  ADRENAL  GLANDS. 
Hemorrhages  into  the  adrenal  glands  are  not  uncommon,  and  are  espe- 
cially likely  to  occur  in  the  new-bom.     Cancer  has  been  found  in  rare 
cases.     Neither  of  these  conditions  is  of  clinical  importance. 

ADDISON'S  DISEASE. 

Etiology. — Addison's  disease  is  even  more  rare  in  children  than  in 
adults,  only  about  twenty  cases  having  been  reported.  The  cause  of  the 
disease  is  still  an  open  question.  The  same  symptoms  occur  when  differ- 
ent pathological  conditions  are  present.  The  adrenal  glands  are  supposed 
to  furnish  an  internal  secretion  -which  is  necessary  for  normal  metabo- 
lism, and  a  loss  of  this  secretion  is  considered  by  some  writers  to  give 
rise  to  the  symptoms,  while  others  believe  that  the  disease  is  dependent 
upon  changes  in  the  ganglia  of  the  sympathetic  nervous  system  of  the 
abdomen. 

Pathological  Anatomy. — The  pigmentation  A^aries  from  a  light  yellow 
to  a  deep  bronze.  It  is  usually  diffuse,  and  is  most  intense  on  the  exposed 
parts  of  the  body,  such  as  the  head  and  hands,  and  in  the  flexures,  around 
the  nipples  and  about  the  genitals.  The  mucous  membranes  of  the  mouth 
and  vagina  are  likewise  pigmented,  but  the  palms  and  soles  remain  free  for 
a  long  time.     Small  areas  of  leucoderma  may  appear. 

Symptoms. — The  onset  is  usually  insidious.  Progressive  loss  in 
strength,  with  symptoms  of  secondary  anaemia  entirely  out  of  proportion 
Jo  the  degree  of  aneemia  present,  and  a  characteristic  discoloration  of  the 
skin  are  the  conspicuous  symptoms  of  the  disease. 

Vomitmg  and  diarrhoea  are  especially  common  when  the  disease  occurs 
in  children.  Nervous  symptoms  are  sometimes  marked,  and  are  of  the 
same  character  as  those  we  see  in  cases  of  severe  secondary  anaemia. 
The  blood,  however,  shows  only  a  slight  degree  of  anaemia.  There  is  no 
emaciation  except  in  the  later  stages. 

The  course  of  the  disease  is  progressive,  with  occasional  remissions, 
the  duration  varying  from  a  few  months  to  one  or  two  years.  Death 
occurs  from  exhaustion  or  from  the  development  of  an  intercurrent  affec- 
tion, which  may  appear  as  some  form  of  tubercular  disease  in  other  parts 
of  the  body. 

On  autopsy  the  adrenal  glands  are  frequently  found  to  be  tubercu- 
lar, but  may  present  no  changes. 

Dlagnosis. — In  the  diagnosis  of  Addison's  disease  other  causes  of  pig- 
mentation of  the  skin  must  be  excluded,  such  as  may  arise  from  arsenic, 


THE   DUCTLESS   GLANDS   L\   LXFANCY   A.\D    CHILDHOOD.  925 

lead,  nitrate  of  silver,  paludism,  and  abdominal  growths.  The  tuberculin 
test  is  often  of  value  as  an  aid  in  Ihe  diagnosis  when  the  cause  is  due  to 
tuberculosis  of  the  adrenal  glands. 

Prognosis. — The  disease  is  nearly  always  fatal.  A  few  recoveries 
have  been  reported. 

Treatment. — The  adrenal  glands  of  the  sheep  have  of  late  been  used 
frequently  in  the  treatment,  and  in  a  few  cases  with  improvement  in  the 
symptoms.  The  remedy  is  worthy  of  a  trial,  but  the  results  are  usually 
very  disappointing.  The  glands  may  be  given  raw  or  slightly  cooked,  in 
the  form  of  a  glycerin  extract,  or  as  a  dry  extract  in  talDlets.  From  one- 
half  to  one  gland  may  be  given  daily,  or  one-grain  doses  of  the  dried 
extract  three  times  a  day.  General  treatment  and  measures  directed  to 
the  control  of  the  symptoms  are  indicated. 


DIVISION  XVI. 

DISEASES    OF    THE    NERVOUS    SYSTEM. 


We  are  much  more  likely  to  meet  with  nervous  phenomena  of  the 
most  diverse  varieties  in  children  than  in  adults.  In  like  manner  we 
meet  with  the  most  widely  differing  clinical  symptoms;  Symptoms  which 
if  occurring  in  adults  would  be  significant  of  serious  lesions  of  the  ner- 
vous system  may  arise  in  children  from  simple  reflex  conditions  which 
only  simulate  and  do  not  represent  actual  disease. 

Children  are  much  more  apt  to  become  unconscious,  to  have  convulsive 
attacks,  and  to  show  disturbance  of  the  functions  of  important  nervous 
centres  from  reflex  irritation,  than  are  adults.  The  whole  cerebro-spinal 
system  in  infancy  and  early  childhood  is  so  impressionable,  so  excitable, 
and  so  hypersensitive  to  even  slight  grades  of  irritation,  that  symptoms 
of  a  nervous  type,  whether  primary  or  secondary,  dominate  all  others. 

Reflex  phenomena  are  so  much  more  numerous  than  those  which 
arise  from  organic  lesions,  and  are  so  irregular  in  their  manifestations, 
that,  from  a  diagnostic  point  of  view,  they  are  most  important.  They 
also  enter  into  all  disturbances  of  the  nervous  system,  whether  functional 
or  organic,  to  such  a  degree  that  what  we  have  learned  concerning  cere- 
/^  iDral  localization  in  the  adult  becomes  of  much  less  value  in  the  young 
subject. 

The  reader  is  referred  to  especial  works  on  the  nervous  diseases  of 
children  for  the  details  of  examination  and  cerebral  localization,  and  we  can 
recommend  particularly  the  "  Nervous  Diseases  of  Children,"  by  Sachs. 

Instability  and  irritability  of  the  nervous  system,  both  peripheral  and 
central,  are  characteristic  of  the  early  periods  of  development,  making 
certain  nervous  diseases  of  children  peculiar  to  them  as  compared  with 
adults.  Many  weeks  are  required  before  the  peripheral  nerves  have  ac- 
quired their  complete  function,  and  the  brain  and  spinal  cord  do  not 
attain  their  full  development  for  months  and  years.  A  simple  heightened 
temperature  or  increase  of  vascular  pressure  in  the  brain  and  cord  may 
cause  such  irritation  of  the  nervous  centres  that  the  most  varied  symp- 
toms, such  as  delirium,  somnolence,  and  twitching,  may  arise.  On  the 
other  hand,  serious  nervous  disturbances  may  in  childhood  follow  the 
acute  infectious  diseases,  and  again  there  may  be  a  complete  arrest  of 
926 


DISEASES    OF   THE    NERVOUS    SYSTEM.  927 

development  of  the  central  nervous  system,  which  may  be  temporary  or 
permanent. 

As  stated  by  Sachs,  childhood  is  exempt  only  from  the  diseases  due 
to  senile  deterioration  from  degeneration  and  sclerosis  of  the  brain  and 
spinal  cord,  and  is  relatively  free  from  those  due  to  toxic  agents,  such  as 
alcohol,  metallic  poisons,  and,  acquired  syphilis ;  the  effects,  however,  of 
such  diseases  in  the  parents  are  shown  by  inheritance  in  the  cliildren. 

CONVULSIONS. -ECLAMPSIA  INFANTUM. 

Attacks  of  motor  disturbance  represented  by  continuous  rigidity  or 
contractions  of  one  or  more  groups  of  muscles,  lasting  for  a  variable 
time  and  usually  accompanied  by  unconsciousness,  are  designated  con- 
vulsions.    A  convulsion  is  a  symptom  and  not  a  disease. 

Convulsions  may  be  divided,  as  to  their  type,  into  (1)  donic  and  (2) 
tonic  J  as  to  their  form,  into  (V)  general  and  (2)  partial;  and  as  to  the 
seat  of  irritation  which  causes  them,  into  (I)  central  and  (2)  jyey^pheral. 

The  clonic  convulsion  is  an  active  spasmodic  contraction  of  the  mus- 
cles followed  by  immediate  relaxation.  The  convulsions  of  epilepsy  are 
illustrative  of  this  type. 

The  tonic  convulsion  is  a  more  or  less  continued  spasmodic  rigidity  of 
tlie  muscles.     This  type  is  seen  in  tetanus  neonatorum. 

The  seat  of  irritation  which  produces  the  convulsion  is  very  varied. 
It  may  be  a  lesion  of  the  central  nervous  system  or  of  the  peripheral 
nerves ;  in  the  former  case  the  convulsions  are  spoken  of  as  central,  in 
the  latter  they  are  termed  reflex.  Convulsions  are  much  more  apt  to 
occur  in  infancy  than  in  later  childhood  and  in  adult  life,  probably  be- 
cause the  power  of  inhibition  is  not  developed  in  the  former,  and  the  child 
is,  therefore,  rendered  susceptible  to  eclamptic  attacks  from  the  most  varied 
causes.  In  the  resulting  mental  condition  we,  therefore,  find  an  analogy 
between  infantile  convulsions  and  hysteria  in  the  adult.  "We,  there- 
fore, not  only  meet  with  convulsive  attacks  more  frequently  in  very  early 
life,  but,  as  a  rule,  we  are  led  to  look  upon  these  convulsive  attacks  as  of 
much  less  import  than  in  the  older  subject.  The  reason  for  this  is  that 
the  causes  of  reflex  convulsions  in  infancy  are  innumerable,  and,  as  a 
rule,  do  not  result  seriously,  while  in  older  children  and  in  adults  con- 
vulsions are  almost  always  representative  of  some  serious  central  lesion. 
Convulsions  are  so  common  in  infancy  that  they  have  been  compared  to 
the  chill  which  occurs  in  tha  initial  stage  of  many  diseases  arising  in 
adults.  The  various  acute  diseases  accompanied  by  high  temperature, 
such  as  pneumonia  and  the  exanthemata,  are  very  commonly  preceded 
by  a  convulsion,  and  a  chill  is  rare  under  these  conditions  in  infancy. 
We  must,  however,  not  be  misled  by  the  frequency  and  comparatively 
benign  character  of  convulsions  in  infancy  and  by  the  rule  that  they  are 
not  fatal.  The  convulsions  of  infancy  may  represent  just  as  serious  con- 
ditions as  they  do  in  later  life,  and  are  to  be  looked  upon  as  a  grave 


928  PEDIATRICS. 

symptom  until  we  can  be  sure,  by  eliminating  serious  organic  lesions  as 
a  cause,  that  we  are  dealing  with  one  of  the  common  and  mild  forms  of 
this  phenomenon.  The  convulsion  does  not  in  itself  show  us  whether 
it  is  the  result  of  serious  or  of  benign  disease,  and  the  convulsions  which 
occur  from  some  organic  lesion,  such  as  cerebro-spinal  meningitis,  may 
differ  in  no  way  from  those  Avhich  arise  from  some  simple  cause,  such  as 
indigestible  food. 

General  Symptoms.-^Wc  are  frequently  called  to  see  infants  in  convul- 
sions where  the  convulsion  is  the  first  and  only  manifestation  of  the  dis- 
ease. After  a  few  signs  of  uneasiness  the  infant  suddenly  becomes  rigid 
for  a  second  or  two,  makes  a  sound  as  though  choking,  the  eyes  turn  up- 
Avard  and  become  fixed,  there  may  be  strabismus,  the  skin  becomes  some- 
what cyanotic,  and  then  the  convulsive  movements  begin.  The  eyelids 
open  and  shut ;  the  face  and  usually  the  head  are  drawn  to  one  side ;  the 
fingers  are  clinched,  and  the  arms  and  legs  move  up  and  down.  The 
back  may  at  times  be  somewhat  arched  and  the  head  retracted.  The 
infant  is  apt  to  foam  at  the  mouth  to  a  greater  or  less  extent ;  it  is  perfectly 
unconscious,  and  the  breathing  soon  becomes  stertorous.  These  symp- 
toms, after  lasting  for  two  or  three  minutes,  are  followed  by  complete  re- 
laxation, an  apparent  state  of  coma,  and  sleep.  The  child  on  awakening 
may  be  bright  and  well,  or  the  convulsion  may  recur  and  continue  for  a 
much  longer  time,  as  in  one  of  my  cases,  in  which  an  infant  had  fifty-two 
convulsions  in  twenty-four  hours  and  yet  recovered.  There  may  be  in- 
voluntary discharges  of  urine  and  faeces. 

The  convulsive  movements  may  affect  the  entire  body  and  limbs, 
including  the  face,  or  they  may  affect  only  certain  groups  of  muscles. 
Thus,  they  may  be  localized,  as  in  one  limb,  or  they  may  be  unilateral 
or  bilateral. 

Convulsions  of  Central  Orig-in — The  most  unportant,  on  account  of 
their  serious  nature,  are  those  convulsions  which  are  of  central  origin. 
Convulsions  of  this  nature  may  occur  in  any  disease  which  is  represented 
by  a  high  temperature,  such  as  insolation,  meningitis,  the  exanthemata, 
pneumonia,  or  other  diseases.  In  these  cases  the  convulsions  are  pro- 
duced either  by  the  action  of  the  high  temperature  on  the  motor  centres 
of  the  brain,  or  by  the  direct  action  of  the  special  toxic  agent  which  is 
producing  the  disease.  These  convulsions,  as  a  rule,  are  general,  and  are 
produced  by  the  diffuse  action  of  the  poison.  In  this  class  of  cases  it  is 
probable  that  there  is  an  extremely  hypersemic  condition  of  the  blood- 
vessels of  the  central  nervous  system.  The  convulsions  may  also,  in 
contradistinction  to  the  supposed  theory  of  active  hyperaemia  of  the  blood- 
vessels and  the  high  temperature,  be  produced  by  vascular  stasis  and  a 
normal  or  subnormal  temperature.  This  form  may  occur  in  the  course 
of  pertussis  or  of  cardiac  disease.  Again,  central  convulsions  are  sup- 
posed to  be  caused  by  an  anaemic  condition  of  the  blood-vessels  of  the 
brain,  such  as  may  arise  from  loss  of  blood  or  from  exhausting  diarrhoea. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  929 

Such  toxic  agents  as  are  represented  by  drugs  of  various  kinds,  as  bella- 
donna, lead,  and  other  poisons  giving  rise  to  either  acute  or  chronic 
poisoning,  may  produce  general  clonic  convulsions.  Mental  disturbance, 
such  as  sudden  fright,  has  also  been  known  to  produce  a  convulsive 
attack.  In  all  these  classes  of  cases  the  convulsions  may  be  partial  and 
clonic  instead  of  general,  although,  as  a  rule,  they  are  general,  owing  to 
the  diffuse  character  of  the  irritation.  In  addition  to  these  convulsions 
which  arise  from  a  diffuse  cause  are  others  in  which  a  local  lesion  having 
occurred  in  the  brain  from  morbid  growths,  embolism,  thrombosis,  hem- 
orrhage, or  any  other  cause,  a  disorganization  of  a  portion  of  the  brain 
has  resulted.  As  these  lesions  are  generally  focal  in  their  distribution, 
the  convulsions  are  apt  to  be  localized  and  hemiplegic  in  character  as  in 
cerebral  paralysis. 

A  number  of  diseases  can  by  their  direct  effects,  irrespective  of  the 
temperature  which  accompanies  them,  produce  convulsions.  Thus,  con- 
vulsions occur  not  uncommonly  in  the  course  of  nephritis,  in  which  they 
are  usually  called  uraemic,  in  intestinal  autointoxication,  malaria,  and  in 
other  diseases.  Direct  pressure  from  tumors  of  the  brain  or  from  hydro- 
cephalus may  in  like  manner  cause  convulsions  of  either  a  localized  or  a 
general  form.     Finally,  we  may  have  these  nervous  explosions  in  epilepsy. 

It  will  be  well  to  remember  that  this  entire  class  of  central  convulsions 
emanates  from  the  brain  ;  and  also  that  when  the  convulsions  are  unilat- 
eral or  localized  we  should  suspect  a  central  rather  than  a  peripheral 
origin. 

Convulsions  of  Peripheral  or  Reflex  Origin. — The  other  class  of 
convulsions  spoken  of  as  of  peripheral  origin,  and  which  are  called  reflex, 
have  so  many  causes  that  it  would  scarcely  be  advisable  to  attempt  to 
enumerate  them  all.  Convulsions  of  this  class  may  arise  from  almost 
any  source  in  infants  whose  nervous  system  is  so  easily  irritated  that  the 
slightest  cause  may  produce  a  nervous  explosion.  The  disease  which 
most  commonly  gives  rise  to  convulsions  of  the  reflex  form  is  rhachitis. 
Rhachitic  children  seem  to  be  predisposed  to  spasmodic  attacks  of  all 
kinds,  and  a  general  clonic  convulsion  in  children  with  rhachitis  corre- 
sponds to  the  spasmodic  contractions  in  the  larynx  which  occur  in  rhachitis, 
and  which  is  spoken  of  as  laryngospasmus. 

There  is  no  special  lesion,  in  connection  with  the  rhachitis,  which 
necessarily  gives  rise  to  convulsions,  but  all  the  tissues  in  this  disease  are 
especially  sensitive  to  causes  which  may  produce  reflex  explosions.  It  is 
possible  that  as  a  result  of  the  disturbed  metabolism,  toxins  are  formed 
which  by  autointoxication  give  rise  to  the  convulsions. 

The  most  common  cause  of  reflex  convulsions  in  infants  is  improper 
food.  Convulsions  from  i  his  cause  arise  not  only  when  manifestly  indi- 
gestible articles  are  given  to  young  children,  but  even  in  infants  who  are 
being  fed  from  the  breast.  In  the  early  days  and  weeks  of  life,  before  the 
breast  has  acquired  its  normal  functions  connected  with  the  elaboration  of 

59 


930  PEDIATRICS. 

milk  in  which  the  solids  are  in  proper  proportion  to  each  other  and  to  the 
water,  it  is  not  uncommon  for  the  infant  to  have  convulsions  produced 
by  a  disturbance  of  the  mammary  function.  In  cases  of  this  kind  it  is 
usually  found  that  the  percentage  of  the  proteids  is  high,  and  that  the  con- 
vulsions will  continue  until  this  high  percentage  has  been  lessened,  if  the 
infant  is  allowed  to  continue  to  nurse.  Whether  the  teeth  of  themselves 
during  their  development  are  a  source  of  sufficient  irritation  to  produce 
convulsions  has  been  cjuestioned  by  many  observers.  It  is,  however,  evi- 
dent that  during  the  different  periods  of  dentition  reflex  convulsions  are 
more  apt  to  occur  than  when  a  tooth  is  not  disturbing  the  infant's  nervous 
system.  In  addition  to  the  convulsions  arising  from  improper  food  in  the 
stomach  during  the  dental  period,  foreign  bodies  in  the  intestine,  whether 
in  the  shape  of  food  or  in  that  of  intestinal  parasites,  may  cause  reflex 
convulsions.  Foreign  bodies  in  the  nose  and  in  the  ear  have  been  known 
to  produce  convulsions,  as  has  also  an  inflamed  tonsil  in  the  initial  stage 
of  a  follicular  tonsillitis.  Hot  baths  are  so  often  given  to  infants  when 
they  are  in  convulsions  that  they  should  be  spoken  of  as  a  source  of  con- 
vulsions, for  they  have  been  known  to  produce  this  result  when  care  has 
not  been  taken  to  test  the  temperature  of  the  bath  before  the  infant  is  put 
into  it.  Mental  disturbances,  such  as  arise  from  fright  and  other  causes, 
are  also  etiological  factors  in  reflex  convulsions. 

Prognosis  in  Convulsions. — The  prognosis  in  infantile  convulsions 
varies  with  the  especial  cause.  On  recovering  from  the  attack  the  infant 
may  show  signs  of  some  serious  central  lesion,  such  as  paralysis,  or  may 
be  left  apparently  perfectly  well.  A  single  convulsion  followed  by  per- 
fect recovery  is  of  slight  consequence,  but  when  the  convulsive  attacks 
recur  frequently  and  last  longer  than  in  the  attacks  which  have  just 
been  mentioned,  the  prognosis  becomes  more  grave.  Even  though  no 
central  lesion  be  present,  continued  convulsions  may,  by  the  shock  to 
^ — ^he  infant's  vitality,  finally  cause  death  from  exhaustion  ;  or  death  may 
occur  from  spasm  of  the  glottis.  Numerous  convulsions,  however,  do 
not  necessarily  lead  to  a  fatal  issue.  We  must,  therefore,  irrespective  of 
the  cause  or  the  apparent  result  of  a  convulsion,  always  look  upon  it  as 
a  grave  symptom  and  endeavor  to  prevent  its  recurrence. 

Treatment. — ^When  summoned  to  treat  an  infant  who  is  in  con- 
vulsions, we  should  first  see  that  the  bath,  in  which  we  usually  find 
that  it  has  been  immersed,  is  not  too  hot,  and  should  order  the  infant  to 
be  taken  out  of  the  bath  before  it  becomes  conscious,  or  it  may  be  so 
frightened  as  to  excite  again  the  reflex  spasm.  The  thorax  should  be 
quickly  examined  for  pulmonary  and  cardiac  lesions,  and  inquiries  should 
be  made  as  to  the  history  of  the  case,  with  special  reference  to  the  infant's 
diet.  The  temperature  should  be  taken,  and  the  fontanelle  be  examined 
for  bulging  as  an  indication  of  increased  intracranial  pressure,  and  for 
depression  as  evidence  of  lowered  vitality. 

Having  obtained  this  information,  we  can  eliminate  a  number  of  causes 


DISEASES   OF  THE   NERVOUS   SYSTEM.  931 

for  the  attack,  such  as  the  onset  of  one  of  the  exanthemata  if  the  tempera- 
ture is  normal,  and  reflex  convulsions  from  food  or  from  foreign  bodies 
in  the  nose  or  the  ear.  If  the  convulsions  arise  from  exhaustion,  stimu- 
lants should  be  given  at  once,  and  if  the  convulsions  continue,  the  gen- 
eral treatment  which  is  adapted  for  all  forms  of  convulsions  is  indicated. 
The  treatment  should  be  directed  to  the  especial  cause  of  the  convulsion, 
if  any  can  be  determined.  As,  however,  it  is  often  impossible  when  the 
convulsion  is  present  to  determine  whether  it  is  of  central  or  of  periph- 
eral origin,  it  becomes  necessary  to  endeavor  to  control  the  attack  at  once 
by  general  treatment.  For  this  purpose  the  mhalation  of  ether  in  small 
amounts,  and  the  emptying  of  the  bowels  by  means  of  enemata,  are  in- 
dicated. When  the  convulsions  are  of  a  very  severe  type,  continuing 
with  perhaps  intermissions  of  only  a  few  minutes,  and  the  infant's  life  is 
evidently  in  danger  from  the  continuous  shocks  which  are  taking  place  to 
its  nervous  system,  a  rectal  injection  of  from  0.30  to  0.90  gramme  (5  to  15 
grains)  of  bromide  of  potassium  and  from  0.06  to  0.30  gramme  (1  to  5 
grains)  of  hydrate  of  chloral  in  30  c.c.  (1  ounce)  of  warm  water,  repeated 
if  necessary  every  hour  for  three  or  four  doses,  is  indicated.  An  infant  of 
one  month  can  be  safely  given  0.06  gramme  (1  grain)  of  chloral ;  of  six 
months,  double  the  dose  ;  and  of  twelve  months,  treble  the  dose.  If  the 
convulsions  still  continue  and  a  fatal  issue  is  anticipated,  a  subcutaneous 
injection  of  sulphate  of  morphine,  beginning  with  0,001  gramme  (g^-  grain), 
should  be  tried. 

In  most  cases  of  infantile  convulsions,  of  whatever  form,  the  warm 
bath  at  a  temperature  of  not  over  37.7°  C.  (100°  F.)  can  be  used,  for, 
although  it  is  not  in  any  sense  curative,  it  tends  to  quiet  the  nervous  ex- 
citability and  to  lessen  the  muscular  strain  produced  by  the  continuous 
spasmodic  muscular  contractions.  The  class  of  cases  in  which  this  is 
contraindicated  are  those  which  are  caused  by  a  loss  of  blood,  an  anaemic 
condition,  diarrhoea,  and  cardiac  disease,  and  those  in  which  venous  stasis 
is  present  with  a  lowered  temperature.  In  these  cases  stimulants  are 
indicated. 

When  there  are  symptoms  of  the  diseases  which  have  already  been 
spoken  of  which  are  accompanied  by  high  temperature,  the  reduction  of 
the  temperature  by  the  bath  and  the  administration  of  an  antipyretic  are 
indicated.  The  combination  of  0.06  gramme  (1  grain)  of  antipyrin  and 
0.30  gramme  (5  grains)  of  bromide  of  soda,  for  an  infant  of  one  year, 
repeated  at  three  or  four  hour  intervals,  is  very  useful. 

The  treatment  of  convulsions  caused  by  definite  diseases  is  simply 
symptomatic  while  the  convulsions  continue,  and  later  appropriate  treat- 
ment of  the  primary  condition. 

The  following  cases  represent  eclamptic  attacks  from  various  causes  : 

A  little  girl,  six  and  one-half  years  old,  was  healthy  at  birth,  and  had  never  had 
any  disease.     When  three  and  one-half  years  old  she  had  from  time  to  time  convulsions, 


932  PEDIATRICS. 

clonic  in  type.  When  in  the  convulsions  she  did  not  bite  her  tongue.  The  first  con- 
vulsion occurred  when  she  was  three  years  old  ;  the  next  when  she  was  four  years  old  ; 
the  next  when  she  was  four  and  one-half  years  old  ;  and  the  last  one  when  she  was 
five  years  old. 

As  all  these  convulsions  were  apparently  produced  by  the  same  cause,  it  will  only 
be  necessary  to  describe  them  in  a  general  way.  They  were  characterized  by  continuing 
much  longer  than  is  usual  in  infantile  convulsions,  one  of  them  having  lasted  for  one 
hour  and  a  half,  during  which  time  the  hands  were  clinched,  the  eyes  were  rolled  up, 
and  the  entire  body  and  limbs  were  convulsed.  Previous  to  each  attack  the  child  for  a 
number  of  days  had  indefinite  symptoms,  which  she  could  not  describe  accurately, 
connected  with  the  abdomen  and  accompanied  by  a  feeling  of  weakness  and  slight 
m.uscular  twitching. 

At  the  time  of  the  earlier  attacks  her  mother  found  that  these  symptoms  could  be 
dissipated  and  a  convulsion  apparently  prevented  by  giving  her  a  dose  of  castor  oil  about 
once  a  week.  After  the  third  convulsion  she  passed  a  lumiu'icoid  worm.  From  that 
time  whenever  she  showed  the  premonitory  symptoms  of  a  convulsion  she  was  treated 
with  santonin  followed  by  a  cathartic,  a  lumbricoid  worm  each  time  was  passed,  and 
the  symptoms  disappeared.  When  she  was  five  years  old  she  was  thoroughly  treated 
for  these  lumbricoid  worms  with  santonin,  and  after  a  large  ascaris  had  been  passed 
the  nervous  symptoms  ceased  entirely.  The  child  when  last  seen  had  not  had  a  con- 
vulsion for  over  a  year.     There  had-  been  no  reappearance  of  the  parasites. 

This  child  represents  the  class  of  cases  described  as  reflex  convulsions,  the  cause 
of  the  peripheral  irritation  being  an  intestinal  parasite. 

Another  case  was  that  of  an  infant,  four  months  old.  Her  moiher,  who  was  strong 
and  well  and  apparently  had  plenty  of  good  breast-milk,  nursed  her  at  birth.  When 
she  was  three  months  old  she  began  to  have  convulsions,  which  occurred  almost  every 
hour.  Suspecting  that  the  proportion  of  solids  in  the  breast-milk  was  too  high  for  the 
infant  to  digest,  and  that  it  was  producing  a  peripheral  irritation  which  was  the  cause 
of  the  reflex  convulsions,  we  had  an  analysis  of  the  milk  made,  and  found  that  the  pro- 
teids  showed  a  percentage  of  from  4  to  5.  The  infant  was  then  fed  with  a  carefully 
modified  milk  in  which  the  percentage  of  the  proteids  was  made  1.  Within  a  few  hours 
the  convulsions  ceased,  and  they  have  never  returned. 

Acase  similar  to  the  one  just  described  was  that  of  a  boy  three  weeks  old,  previ- 
ously healthy  and  strong,  and  digesting  his  mother's  milk  perfectly  ;  he  was  weaned 
and  given  by  mistake  a  mixtui'e  containing  a  total  proteid  of  3.50.  He  then  began  to 
-have  convulsions,  which  continued  until  a  new  mixture  was  giv8n,  in  which  the  total 
proteid  was  1.50,  when  they  ceased. 

CHOREA.    -SYDENHAM'S   CHOREA. 

Chorea  is  a  disease  characterized  by  irregular  and  involuntary  mus- 
cular movements  without  loss  of  consciousness,  and  affecting  the  muscles 
of  volition. 

The  disease  is  rare  in  infancy,  but  may  occur  in  the  early  months  of 
life.  It  seldom  begins  after  puberty.  It  is  most  apt  to  begin  and  is  most 
marked  in  its  symptoms  during  the  period  of  the  second  dentition, — that 
is,  during  the  period  of  active  growth,  from  six  years  to  puberty.  The 
greatest  number  of  cases  is  found  among  the  female  sex  and  among  those 
who  do  not  receive  sufficiently  nutritious  food.  A  sharp  distinction 
should  be  made  between  the  disease  chorea,  with  its  characteristic  chorei- 
form symptoms,  and  the  same  choreiform  symptoms  resulting  from  other 
diseases,  sometimes  represented  by  central  nervous  lesions,  sometimes  by 


DISEASES   OF  THE   NERVOUS   SYSTEM.  933 

purely  reflex  causes.  It  will  save  much  useless  reading  of  the  literature 
of  chorea  and  much  profitless  discussion  as  to  its  etiology  and  pathology 
if  this  distinction  is  borne  in  mind.  Eliminating  those  cases  showing 
choreiform  movements  which  are  due  to  gross  lesions  of  the  nervous  sys- 
tem, such  as  the  post-hemiplegic  and  congenital  forms,  we  can  at  once  very 
materially  reduce  the  number  of  cases  of  true  chorea.  In  like  manner  we 
should  separate  from  true  chorea  those  cases  of  peripheral  irritation  in 
which  the  partial  choreiform  symptoms  are  evidently  reflex  and  can  be 
cured  by  removal  of  the  cause.  Examples  of  these  reflex  choreiform 
symptoms  are  the  facial  chorea  from  naso-pharyngeal  irritation  and  the 
partial  choreiform  movements  occasionally  arising  from  errors  of  refraction 
and  ocular  insufficiency.  The  consideration  of  these  anomalous  forms 
of  chorea  belongs  with  the  diseases  in  which  they  occur. 

Etiology. — Chorea  can  occur  in  connection  Avith  other  diseases,  such 
as  measles,  scarlet  fever,  and  typhoid  fever,  although  this,  in  our  expe- 
rience, rarely  occurs,  and  even  then  chiefly  among  the  poorly  cared-for. 
A  certain  number  of  cases  have  so  directly  followed  intense  fright  that  we 
must  acknowledge  acute  mental  conditions  as  a  cause.  The  disease  which 
is  most  frequently  associated  Avith  chorea  is  rheumatic  fever.  The  per- 
centage of  cases,  however,  in  which  this  association  takes  place  is  difficult 
to  determine.  This  difficulty  arises  from  the  want  of  uniformity  in  the 
reported  cases  of  different  observers,  due  to  their  different  ideas  as  to 
what  constitutes  rheumatic  fever. 

The  association  of  chorea  and  rheumatic  fever  is  so  notable,  and  cases 
of  chorea  so  frequently  follow  closely  or  alternate  with  attacks  of  rheumatic 
fever,  that  there  is  considerable  reason  for  believing  that  chorea  is  in 
certain  cases  one  of  the  manifestations  of  this  infection.  The  frequent 
association  of  chorea  with  signs  of  endocarditis,  with  the  fact  that  the  great 
majority  of  cases  of  endocarditis  are  due  to  the  rheumatic  infection,  is 
further  evidence  of  the  possible  rheumatic  origin  of  chorea.  There  is  no 
reason  for  believing  that  chorea  is  always  due  to  rheumatic  infection.  It 
is  probably  a  particular  nervous  manifestation  due  to  a  variety  of  causes, 
of  which  rheumatic  fever  is  one.  Overwork  at  school  during  the  first  part 
of  the  school  year  has  so  often  been  shown  to  result  in  an  attack  of  chorea 
in  the  spring  and  in  a  recurrence  in  the  autumn  on  returning  to  school, 
that  it  should  be  recognized  in  considering  the  different  causes  of  the  dis- 
ease. Strain  of  the  ocular  muscles  has  been  considered  an  exciting  cause 
of  chorea,  but,  beyond  producing  in  some  cases  choreiform  symptoms,  it 
cannot  be  considered  true  chorea.  Any  local  causes  of  irritation,  such  as 
adenoids  or  parasites,  and  such  conditions  as  bad  hygiene  and  improper 
food,  may  be  contributing  causes  of  choreic  manifestations. 

An  hereditary  neuropathic  predisposition  has  lorg  held  a  prominent 
place  in  the  etiology  of  chorea. 

Heart  murmurs  of  a  hasmic  nature  may  occur  in  chorea  as  in  any 
other  disease  of  a  debilitating  nature.     They  should,  however,  always  be 


934  PEDIATRICS. 

looked  upon  seriously,  as  possibly  indicating  an  nisidious  form  of  organic 
endocarditis,  which,  instead  of  being  evanescent  and  passing  away  entirely 
with  the  recovery  of  the  chorea,  may  either  seriously  disable  the  heart  or 
lead  to  a  fatal  issue.  In  all  cases  of  chorea  we  should  watch  carefully  for 
the  development  of  cardiac  lesions. 

Pathological  Axatomt. — There  are  a  large  number  of  cases  of  chorea 
in  which  the  disease  is  found  to  have  no  apparent  pathological  lesion.  Its 
symptoms,  however,  show  us  that  the  morbid  process  is  located  in  some 
part  of  the  central  nervous  system.  Whatever  the  nature  of  the  lesion, 
it  is  represented  by  a  profound  excitement  of  the  motor  centres,  presum- 
ably due  to  their  inanition,  and  is  accompanied  by  a  temporary  ina- 
bility of  these  centres  to  recover  themselves.  Many  lesions  have  been 
described  as  occurring  in  chorea,  but  in  the  pure  cases  (Sydenham's 
chorea)  of  which  we  are  speaking  which  really  represent  the  disease, 
there  is  no  lesion  which  with  our  present  knowledge  we  can  say  is  charac- 
teristic. 

Symptoms. — Chorea  may  be  in  its  distribution  general  or  partial ;  in  its 
course  acute,  subacute,  or  chronic.  In  many  cases  the  disease  is  exceed- 
ingly mild  in  its  symptoms  and  is  of  a  benign  type ;  in  others  it  assumes 
a  severity  which  seems  to  threaten  life.  The  beginning,  although  at  times 
sudden,  as  from  fright,  is,  as  a  rule,  gradual,  at  first  a  few  muscles  only 
being  affected.  The  child  becomes  fretful  and  impatient.  Its  irritalDility 
must  carefully  be  differentiated  from  bad  temper,  for  which  the  symptoms 
are  apt  to  be  mistaken  by  the  family.  The  clinical  picture  of  the  disease 
is  a  jerky,  irregular,  involuntary,  and  purposeless  contraction  and  relaxa- 
tion of  the  muscles,  which  usually  begin  in  the  fingers,  hands,  shoulders 
and  face.  There  is  an  irregular,  uncertain  action  of  the  part  affected,  and 
efforts  of  the  will  only  partly  control  the  movements.  As  the  disease 
progresses,  the  voluntary  control  of  the  muscles  diminishes  more  and 
more,  and  at  times  disappears  entirely. 

The  movements  ordinarily  cease  during  sleep,  but  in  severe  cases 
they  continue  and  even  interfere  with  it.  The  skin  may  be  worn  off  of 
prominent  portions  of  the  body  by  friction,  especially  of  the  knees  and 
elbows.  At  times  the  child  is  unable  to  walk,  on  account  of  weakness. 
The  speech  may  become  slow  and  indistinct,  from  the  affection  of  the 
muscles  of  the  tongue  and  of  the  larynx,  and  even  mastication  and  degluti- 
tion may  prove  difficult.  In  very  severe  cases  the  difficulty  in  speech 
may  be  enhanced  by  the  mental  condition,  which  may  be  represented  by 
dulness  and  apathy,  and  the  child  cannot  or  will  not  speak.  The  tendon 
reflexes  are  lessened  in  severe  cases.  The  muscles  grow  weak  and  soft, 
and  there  is  considerable  emaciation.  There  is  usually  loss  of  appetite, 
and  the  bowels  are  often  constipated.  The  urine  and  its  urea  have  been 
found  to  be  increased  during  the  course  of  the  disease.  The  dynamom- 
eter usually  shows  impaired  muscular  power.  In  certain  cases  the 
muscles  of  the  extremities  on  one  side  of  the  body  are  principally  or 


DISEASES  OF   THE   NERVOUS   SYSTEM.  935 

alone  affected  (hemichorea).     These  cases  do  not  differ  from  the  ordmary 
bilateral  cases  in  any  way  except  in  this  respect. 

The  choreiform  movements  are  so  prominently  a  feature  of  the  disease 
that  one  may  underestimate  the  seriousness  and  extent  of  the  mental 
symptoms,  which  often  persist  after  the  muscular  inco-ordination  has  sub- 
sided. The  nature  of  the  child  in  very  severe  cases  seems  to  change, 
irritability,  disobedience,  impairment  of  the  powers  of  memory  and 
application,  and  spells  of  crying  and  general  nervous  excitability  may  be 
the  early  manifestations  of  a  condition  of  mental  derangement  which 
subsequently  give  rise  to  delusions,  hallucinations  and  even  mania. 
Cases  have  been  reported  of  this  nature  which  have  terminated  fatally. 
In  some  cases  there  may  be  involuntary  evacuations  of  the  fseces  and 
urine.  The  disease  is  distinct  from  epilepsy,  and  there  is  little  danger  of 
the  patient  becoming  epileptic  unless  it  happens  to  develop  in  an  indi- 
vidual who  is  predisposed  to  that  condition. 

Prognosis. — Chorea  is  very  apt  to  show  relapses  and  to  recur  for 
several  years.  Although  often  obstinate  in  the  persistency  of  its  symp- 
toms, yet  it  may  be  said  to  be  self-limited,  and,  as  a  rule,  to  recover,  pro- 
vided no  complications,  such  as  of  the  heart,  arise.  The  time  which 
elapses  before  complete  recovery  is  very  variable  ;  mild  cases  may  recover 
under  proper  treatment  in  six  weeks  but  the  severer  forms  usually  extend 
over  a  period  of  three  or  four  months  in  spite  of  all  efforts  at  treatment. 
Although  chorea  is  considered,  as  a  rule,  a  benign  disease,  yet  we  must 
always  look  upon  it  as  a  serious  disturbance  until  we  are  sure  that  we  are 
dealing  with  the  usual  mild  form  of  the  affection.  The  following  case 
illustrates  how  careful  we  should  be  to  give  a  guarded  prognosis  in  the 
e.ariy  stages  of  acute  chorea : 

A  girl,  nine  years  old,  reported  by  Cook  and  Beale,  began  to  have  choreic  moA-e- 
ments,  which  constantly  became  worse.  Delirium  developed,  with  a  slight  fever,  a 
rapid  and  feeble  pulse,  and  a  quick  and  interrupted  respiration.  Death  suddenly  oc- 
curred one  hundred  and  thirty  hours  after  the  onset  of  the  disease.  The  autopsy 
revealed  extreme  anaemia  of  the  pons  and  medulla,  but  no  other  changes  of  note  in 
other  parts  of  the  body. 

We  must  allow  that  even  uncomplicated  chorea  is  a  varying  disease 
as  to  the  severity  of  its  symptoms  and  their  persistence  for  a  longer  or  a 
shorter  time.  We  also  know  that  there  is  a  marked  tendency  to  relapse, 
and  that  the  number  of  relapses  varies  to  a  great  degree.  The  length  of 
the  attack  and  the  response  to  treatment  may  differ  much.  Bearing  these 
facts  in  mind,  we  can  understand  the  rapidity  ^^1th  which  certain  indi- 
viduals are  attacked  or  the  quickness  with  which  they  recover.  Some 
cases  recover  rapidly  under  only  hygienic  treatment,  while  others  are 
apparently  unaffected  by  any  drug  whatever.  When  heart-murmurs, 
evidently  representmg  organic  disease,  appear,  it  is  often  a  cause  for  com- 
ment at  the  comparatively  slight  discomfort  which  the  cai'diac    lesions 


936  PEDIATRICS. 

entail.  At  times,  again,  it  is  surprising  how  rapidly  fatal  are  some  cases 
which  are  complicated  by  cardiac  disease,  and  how  uncontrolled  they  are 
by  any  treatment  whatsoever.  We  have  seen  well-marked  cases  get  well 
in  from  sixty  to  seventy  days  where  good  food  and  a  small  amount  of 
stimulant  (nux  vomica)  constituted  the  entire  treatment. 

Treatment. — Our  main  reliance  must  be  placed  upon  regulation  of  the 
child's  life  in  such  a  way  as  to  provide  rest,  freedom  from  excitement, 
fresh  air  and  nutritious  food.  Disturbances  in  the  function  of  digestion 
and  excretion  must  be  treated  symptomatically.  If  extreme  muscular 
incoordination  exists  absolute  rest  in  bed  and  even  restraint  is  required. 
In  the  average  case  the  child  should  be  kept  in  bed  and  served  with  a  late 
breakfast.  After  an  hour's  rest  it  may  be  dressed  and  taken  out  of  doors 
for  a  ride  or  walk  for  an  hour,  but  always  within  the  limits  of  fatigue.  It 
should  then  be  undressed,  ^iven  a  tepid  bath,  put  to  bed  and  allowed  to 
rest  for  an  hour  before  and  after  dinner.  This  may  be  followed  by  a 
second  airing  and  if  the  case  is  progressing  favorably  the  patient  may  sit 
up  until  supper  but  should  go  to  bed  immediately  after.  Cold  packs  are 
too  severe  for  the  majority  of  cases,  warm  sedative  baths  are  much  to  be 
preferred.  Skilled  nursing  is  important  in  the  treatment  in  carrying  out 
the  routine  life  outlined  and  in  protecting  the  patient  from  diversions  and 
annoyances  which  aggravate  the  disease.  It  may  be  necessary  to  pad  the 
bed  and  apply  light  splints  to  control  the  movements  of  arms  and  legs 
during  sleep  and  to  guard  against  injury.  Threatened  abrasions  of  the 
elbows  and  knees  from  rubbing  may  be  averted  by  the  use  of  icthyol 
collodion,  a  useful  protective  covering  which  cannot  readily  be  torn  off. 

There  are  no  drugs  that  may  be  called  specifics  in  the  treatment  of 
chorea.  Arsenic  in  the  form  of  Fowler's  solution  (licjuor  potassii  arseni- 
tis)  is  most  beneficial.  One  should  begin  with  small  doses  of  3  minims 
three  times  a  day,  gradually  increasing  it  up  to  10  minims  to  a  dose,  or 
^ — until  physiological  symptoms  are  produced.  On  the  first  appearance  of 
oedema  of  the  eyelids,  nausea  or  diarrhoea  the  arsenic  should  be  at  once 
discontinued  for  a  few  days  until  tlie  symptoms  have  passed  and  then  be 
resumed  in  smaller  and  more  gradually  increasing  doses.  Large  amounts 
which  are  long  continued  may  produce  a  multiple  neuritis,  and,  therefore, 
in  prolonged  cases  there  should  be  periods  during  which  the  arsenic 
should  be  temporarily  omitted.  The  urine  should  be  examined  fre- 
quently for  evidence  of  renal  irritation. 

Bromide  of  soda,  0.6  gramme  (10  grains)  three  times  a  day  may  be 
advantageously  administered  with  the  arsenic  especially  to  control  insom- 
nia and  over-excitement.  In  addition  special  conditions  require  appro- 
priate treatment  such  as  iron  for  aneemia,  salicylates  or  aspirin  for  an 
associated  rheumatic  fever,  stimulants  if  weakness  is  evident,  and  finally 
when  bromides  fail  to  control  extreme  nervous  and  mental  symptoms  one 
may  temporarily  employ  more  powerful  sedatives  such  as  chloral,  urethane, 
veronal,  trional,  sulphonal  or  somnos. 


DISEASES   OF   THE   XERVOUS   SYSTEM.  937 

The  following  cases  illustrate  the  different  phases  of  chorea : 

A  girl,  six  years  old,  represented  one  of  the  milder  forms  of  chorea.  There  was 
no  history  of  nen^ous  or  cardiac  disease  or  rheumatism  in  the  family,  and  the  child 
herself  had  never  been  sick  before. 

She  first  complained  of  pain  in  her  left  hand  and  arm,  and  later  the  muscles  of 
the  arm  began  to  twitch.  Soon  after  the  whole  body  was  affected  in  the  same  way. 
Somewhat  later  it  was  found  that  the  child  could  not  talk  plainly,  and  it  was  with 
some  difficulty  that  she  could  feed  herself.  She  seemed  nervous  and  peevish,  and 
showed  constant  irregular  incoordinate  movements,  chiefly  of  the  face,  mouth,  and 
upper  extremities.  The  legs  were  slightly  affected,  and  sometimes  the  muscles  of  the 
trunk.  There  had  been  no  paralysis  of  the  muscles.  The  eyes  were  normal  in  their 
reaction. 

She  was  treated  chiefly  without  drugs,  and  especial  attention  was  paid  to  giving 
her  a  nourishing  diet,  baths,  gentle  massage,  and  rest  in  bed  in  a  quiet  room.  A 
physical  examination  showed  nothing  abnormal  in  connection  with  the  heart  or  other 
organs.  An  examination  of  the  urine  showed  it  to  be  normal.  Marked  improvement 
was  shown  after  she  had  been  treated  for  two  weeks,  and  at  about  the  forty-second  day 
from  the  onset  of  the  disease  she  had  recovered  completely. 

Another  girl,  thirteen  years  old,  represented  one  of  the  milder  forms  of 
recurrent  chorea. 

She  had  a  number  of  diseases  preceding  her  first  attack  of  chorea.  When  she  was 
two  years  old  she  had  diphtheria,  when  five  years  old,  measles,  when  seven  years  old, 
scarlet  fever,  and  when  eight  years  old,  rheumatism.  When  nine  years  old  she  had  her 
first  attack  of  chorea,  which  occurred  in  the  spring  of  the  year,  and  lasted  for  a  num- 
ber of  months.  This  was  followed  in  the  spring  of  the  next  year  by  a  second  attack. 
In  the  spring  of  the  following  year  she  had  a  third  attack  of  the  disease  ;  at  this  time 
the  incoordinate  movements  were  not  so  marked  as  in  the  previous  attacks,  but  the 
debility  was  greater.  When  she  was  examined  during  this  attack,  it  was  found  that 
the  heart,  although  weak  and  somewhat  irregular,  presented  no  evidence  of  murmurs. 
The  pulse  was  84,  the  temperature  was  normal,  and  there  were  no  signs  of  any  other  dis- 
ease. She  was  treated  at  the  hospital,  and  recovered  in  a  few  months.  In  the  spring 
of  the  next  year  she  had  a  fourth  attack  of  chorea.  At  that  time  nothing  abnormal 
beyond  the  choreic  movements  Avas  noticed.  She  Avas  treated  with  from  0.18  to  0.36 
gramme  (3  to  6  minims)  of  FoAvler's  solution  three  times  a  day,  and  in  a  few  months 
left  the  hospital  apparently  well. 

In  the  spring,  one  year  from  the  beginning  of  the  fourth  attack,  she  entered  the 
hospital  with  a  fifth  attack.  On  this  occasion,  after  using  Fowler's  solution  for  a  few 
weeks  and  not  obtaining  any  special  benefit,  iron  and  nux  vomica  were  giA'en.  She 
gradually  improved  under  this  treatment.  There  remained  for  some  time,  however, 
incoordinate  movements,  which  appeared  especially  when  she  was  embarrassed  by  the 
observation  of  the  people  who  Avere  around  her.  It  Avas  a  case  in  Avhich  a  good  prog- 
nosis could  be  gi\'en,  as  there  Avere  no  cardiac  or  other  complications. 

The  folIoAving  case  illustrates  recurrent  chorea  with  the  development 
of  a  functional  disturbance  of  the  heart,  resembling  organic  disease : 

A  boy,  nine  years  old,  Avas  subject  to  attacks  uf  chorea  for  nearly  four  years.  The 
attacks  usually  came  on  in  the  spring  Avith  considerable  seA-erity,  and  continued  for 
nearly  six  months,  gradually  diminishing  in  intensity  until  the  symptoms  were  scarcely 


938  PEDIATRICS. 

noticeable.  The  child  had  a  history  of  rheumatism,  not,  however,  of  a  high  grade. 
The  attack  began  four  months  previous  to  entering  the  hospital,  and  was  quite  a  severe 
one,  so  that  he  had  been  unable  to  control  the  movements  of  his  hands  and  face  during 
the  day  ;  they  were,  however,  quiet  at  night. 

On  entering  the  hospital  a  physical  examination  showed  a  marked  systolic  mur- 
mur, heard  most  distinctly  at  the  apex  and  transmitted  to  the  axilla.  The  area  of  car- 
diac dulness  was  not  especially  enlarged.  The  urine  was  normal,  and  nothing  else 
abnormal  was  detected  about  the  child. 

He  was  at  first  treated  with  Fowler's  solution,  0.12  gramme  (2  minims),  three 
times  a  day.  After  four  days  the  choreic  movements  became  less  marked  and  the  car- 
diac souffle  less  distinct.  Two  days  later,  however,  the  Fowler's  solution  had  to  be 
omitted,  as  it  caused  nausea  and  vomiting.  At  this  time  there  was  a  double  souffle, 
heard  most  distinctly  over  the  left  third  interspace,  close  to  the  sternum.  A  few  days 
later  Fowler's  solution  was  renewed,  but  as  it  caused  gastric  disturbance,  again  had  to 
be  omitted,  and  it  Avas  found  that  it  could  not  be  given  for  more  than  two  days  at 
a  time  without  causing  puffmess  of  the  face.  The  treatment,  therefore,  consisted  chiefly 
of  rest  in  bed,  good  food,  bathing,  massage,  and  the  administration  of  iron  in  the  form 
of  the  citrate  of-  iron  and  potassium. 

One  month  later  the  choreic  movements  had  decidedly  lessened,  and  the  cardiac 
murmurs  disappeared.  Two  months  from  the  time  he  entered  the  hospital  he  was  free 
from  all  symptoms  of  the  disease. 

The  next  case  illustrates  a  severe  case  of  chorea,  followmg  an  attack 
of  influenza,  and  terminating  fatally,  without  the  development  of  any 
complication  : 

A  boy,  ten  years  old,  had  always  been  delicate,  but  had  had  no  especial  disease, 
such  as  rheumatism,  until  six  weeks  previous  to  the  time  when  we  saw  him,  when  he 
was  said  to  have  had  an  attack  of  epidemic  influenza.  He  recovered  completely  from 
the  disease  in  ten  days.  Three  or  four  days  later  he  began  to  show  symptoms  of  chorea. 
These  symptoms  gradually  increased  in  severity,  and  Anally  Avere  continuous,  except 
when  he  was  asleep.  After  he  had  had  the  chorea  for  one  week  he  was  unable  to  articu- 
late, and  began  to  have  trouble  with  deglutition.  He  soon  lost  the  control  of  his  limbs, 
grew  very  weak,  and  was  confined  to  his  bed.  There  was  considerable  insomnia.  In  the 
second  week  of  the  attack  the  choreic  movements  became  so  violent  as  to  endanger 
his  falling  out  of  bed.  The  temperature  up  to  the  time  when  we  saw  him,  in  the  fourth 
week  of  the  attack,  was  normal.  The  pulse  varied  from  140  to  150,  and  the  respira- 
tions from  35  to  40. 

When  we  saw  him,  at  the  end  of  the  fourth  week  from  the  beginning  of  the  chorea, 
his  mind  was  perfectly  clear  ;  he  had  a  little  pain  in  the  hands  and  shoulders,  appar- 
ently from  the  continual  movements.  He  was  unable  to  articulate  clearly.  There 
was  difficulty  in  swallowing,  and  he  was  considerably  emaciated.  Nothing  abnormal 
was  found  in  the  lungs.  The  heart  was  beating  tumultuously.  The  area  of  cardiac 
dulness  was  very  slightly  enlarged,  but  there  were  no  cardiac  murmurs.  Although  in 
many  of  these  severe  cases  of  chorea  no  evidence  of  cardiac  disease  can  be  obtained 
on  physical  examination  beyond  a  slight  dilatation  of  the  left  ventricle,  yet  some  dis- 
ease of  the  endocardium  or  valves  may  often  be  found  at  the  autopsy.  In  these  cases, 
however,  the  temperature  is,  as  a  rule,  raised.  In  this  case  the  continuous  normal 
temperature  and  the  absence  of  any  signs  of  cardiac  disease  beyond  a  slight  dilatation 
from  the  apparent  weakness  of  the  ventricular  muscles  seemed  to  indicate  that  it  was 
a  case  of  simple  chorea  without  disease  of  any  of  the  organs. 

Although  the  child  was  carefully  nursed  and  remedies  of  various  kinds  were  em- 
ployed to  strengthen  the  action  of  the  heart  and  to  support  his  general  strength,  he 
failed  rapidly,  and  died  of  exhaustion  a  few  days  after  we  saw  him. 


DISEASES   OP   THE   NERVOUS   SYSTEM.  939 

In  the  following  case  (Fig.  191)  we  have  an  example  of  acute  articular 
rheumatism  with  endocarditis,  in  the  course  of  which  chorea  developed 
with  other  complications,  which  terminated  fatally  : 

Fig.  191. 


Rheumatic  arthritis.    Endocarditis.    Cardiac  enlargement.    Chorea.    Female,  8  years  old.  ' 

The  child  was  eight  years  old.  She  had  been  subject  to  attacks  of  rheumatism. 
She  had  not  had  any  especial  diseases,  with  the  exception  of  an  attack  of  measles  when 
she  was  three  or  four  years  old,  until  she  had  an  attack  of  rheumatic  arthritis  when 
seven  and  one-half  years  old.  At  that  time  she  was  confined  to  bed  with  fever,  and 
with  pain,  tenderness,  and  sweUing  in  all  her  joints,  especially  of  the  knees  and  fingers. 
Although  she  recovered  from  the  acute  symptoms  of  the  rheumatism,  she  had  since 
then  never  been  able  to  use  her  arms  and  hands,  nor  able  to  walk  much.  There  was 
no  record  of  the  condition  of  her  heart  during  the  attack  of  rheumatism,  but  there  was 
no  history  of  previous  cardiac  disease.  During  the  course  of  the  rheumatism  there 
were  no  other  especial  symptoms  noticed,  except  that  her  disposition  was  evidently 
m.uch  changed  and  she  became  peevish  and  fretful. 

One  week  before  entering  the  hospital  she  began  to  have  choreic  movements.  They 
were  moderate  in  degree,  but  incessant.  A  few  days  later  the  incoordination  of  the 
muscles  was  also  noticed  when  she  endeavored  to  speak  or  to  swallow.  There  were 
continual  choreic  movements  of  the  eyes,  face,  aiid  fingers,  and,  although  seemingly 
she  could  understand  what  was  said,  she  was  unable  to  speak  clearly.  She  was  much 
emaciated.  Incoordinate  movements  of  all  the  muscles  of  the  face,  eyes,  head,  neck, 
body,  and  extremities  were  present.  The  peculiar  look  which  occurs  in  these  cases, 
expressive  of  embarrassment,  was  clearly  shown.  Although  the  case  was  a  severe  one, 
the  mind  was  not  affected  beyond  a  slight  degree  of  hebetude.  On  physical  examina- 
tion the  lungs  were  found  to  be  normal.  On  examining  the  cardiac  region  the  impulse 
of  the  heart  was  found  to  be  outside  of  the  mammillary  line  and  in  about  the  sixth 
interspace.  On  palpation  the  contractions  of  the  heart  were  clearly  felt,  but  were  irreg- 
ular and  not  so  strong  as  normal,  suggesting  irritability  and  incoordination  of  the  car- 
diac muscles.  On  percussion  there  was  normal  resonance  to  the  right  of  the  sternum 
and  under  its  upper  part  as  far  as  the  third  right  interspace.  There  was  dulness  under 
the  sternum,  beginning  at  the  second  left  interspace,  extending  across  to  the  third  right 
interspace,  and  involving  the  lower  part  of  the  sternum.  The  area  of  cardiac  dulness 
is  marked  in  black  in  Fig.  191.  It  extended  upward  to  the  left  of  the  sternum  as  far 
as  the  second  rib,  then  to  the  left  and  downward  outside  of  the  mammillary  line  until 
it  reached  the  impulse  of  the  heart  in  the  sixth  left  interspace.  On  auscultation  a 
murmur  was  heard  most  distinctly  with  the  first  sound  at  the  apex  of  the  heart,  and 
was  transmitted  to  the  axilla  and  to  both  sides  of  the  back.     This  murmur  was  trans- 


940  PEDIATRICS. 

nutted  to  the  base,  but  gradually  lessened  as  the  area  of  the  large  vessels  at  the  base  of 
the  heart  was  reached.     Nothing  else  abnormal  was  detected  on  physical  examination. 

This  was  a  case  in  which  during  the  course  of  a  rheumatic  attack  an  endocarditis 
had  developed.  This  endocarditis  had  been  foUoAved  by  enlargement,  mostly  repre- 
sented by  dilatation  of  the  left  ventricle.  During  the  course  nf  the  rheumatism  and 
of  the  cardiac  complication  the  chorea  had  developed. 

The  prognosis  in  a  case  like  this  must  be  very  guarded.  In  some  instances  the 
disease,  or  rather  combination  of  diseases,  grows  rapidly  worse,  and  the  child  dies 
seemingly  from  exhaustion.  In  cases  of  a  milder  form  the  child  gradually  recovers  from 
its  chorea  and  from  its  rheumatism,  but  is  left  with  an  organic  disease  of  the  heart 
from  which  it  never  recovers.  The  cardiac  disease,  however,  can  in  most  cases  be 
much  benefited  by  careful  treatment,  especially  by  rest  in  bed.  In  these  cases  the  dila- 
tation grows  decidedly  less,  while  the  heart  becomes  stronger,  and,  as  the  chorea 
passes  away,  may  show  a  normal  area  of  dulness.  We  may  at  any  time  expect  in  place 
of  gradual  improvement  a  decided  increase  in  the  severity  of  the  symptoms.  The  val- 
vular lesion  of  the  heart  may  become  much  more  extensive,  assuming  the  ulcerative 
form  which  is  usually  so  fatal.  The  pericaixlium  may  become  affected,  and  broncho- 
pneumonia occur  as  a  complication. 

The  treatment  in  this  case  was  with  milk  and  stimulants.  It  was  impossible  for 
her  to  take  solid  food,  and  the  milk  was  with  the  greatest  difficulty  introduced  into  her 
mouth. 

The  subsequent  history  of  the  case  was  as  follows  :  The  temperature  rose  to  40°  C. 
(104°  F.),  and  was  accompanied  by  precordial  pain  and  a  pericardial  friction-rub.  liut 
no  physical  signs  of  effusion.  There  was  dulness  under  the  left  clavicle,  but  at  first, 
beyond  rather  indefinite  signs  of  bronchitis,  nothing  abnormal  was  detected  in  the 
lungs.  The  liver  was  somewhat  enlarged.  The  axillary  lymph-nodes  were  enlarged. 
There  was  great  atrophy  of  the  muscles.  There  was  diarrhoea  and  incontinence  of  urine. 
The  hebetude  increased.  Areas  of  dulness  and  diminished  respiratory  sound  were 
detected.  There  was  dyspnoea  and  rapid  failure  in  strength.  The  child  died  on  the 
thirty-seventh  day  from  the  beginning  of  the  disease. 

The  autopsy  showed  the  following  lesions  :  Chronic  pericarditis  and  mediastinitis  ; 
acute  ulcerative  endocarditis  ;  thrombosis  of  the  innominate  and  left  jugular  veins  ; 
broncho-pneuruonia  ;  passive  congestion  ana  redema  of  the  pericardium. 

Various  methods  of  administering  milk  and  stimulants  in  cases  like  the 
preceding  have  been  tried,  but  the  jaws  close  so  spasmodically  when- 
ever a  spoon  is  introduced  between  the  teeth  that  the  milk  is  usually 
spilled  before  it  enters  the  mouth.  The  method  which  we  have  found 
to  be  most  successful  is  by  a  feeding-cup  with  a  rubber  nipple  fitted 
to  the  neck  of  the  cup.  The  rubber  nipple  is  perforated  with  a  large  hole. 
The  soft  rubber  does  not  incite  the  choreic  movements  of  the  jaw  to  the 
degree  that  anything  hard  would  do.  The  Breck  feeder  (page  260)  is 
also  useful  in  these  cases. 

CHOREIFORM  DISEASES. 
Hereditary  or  Hunting-ton's  Chorea. — This  form  of  chorea  differs 
from  Sydenham's  chorea  chiefly  in  its  hereditary  character  and  in  the 
much  greater  degree  of  muscular  incoordination.  It  almost  mvariably 
appears  between  the  ages  of  thirty  and  forty.  It  need  merely  be  men- 
tioned in  connection  with  children  on  account  of  its  hereditary  character. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  941 

Habit  Chorea. — This  condition  is  common  in  children.  It  includes 
simple  incoordinated  movements,  usually  of  the  eyes,  mouth,  shoulder,  or 
thighs.  They  have  been  called  "  habit  spasms  "  or  "  tics."  Imitation  is 
probably  a  strong  factor  in  the  etiology.  It  may  follow  from  true  chorea. 
These  habit  spasms  may  become  chronic  and  persist  throughout  life. 

Treatment. — The  treatment  consists  entirely  of  discipline  and  educa- 
tion of  the  child,  and  the  earlier  this  is  begun  and  the  more  strictly  it  is 
enforced  the  better  will  be  the  results.  The  training  may  be  facilitated  by 
placing  the  child  before  a  mirror,  when  he  may  be  made  more  conscious 
of  the  "  tic,"  and  by  observing  the  degree  to  which  it  may  be  controlled 
by  concentrated  attention  and  will,  may  feel  encouraged  to  persist  in  his 
efforts  until  the  habit  has  been  overcome.  As  these  habit  spasms  are 
often  dependent  upon  peripheral  irritation,  one  should  seek  for  local  causes 
such  as  errors  of  refraction,  adenoids,  and,  if  present,  see  that  they  are  first 
of  all  removed. 

Chorea  Electrica. — This  is  a  very  rare  condition  occurring  in  child- 
hood and  adult  life,  and  seen  chiefly  in  Italy.  It  is  characterized  by 
violent  spasmodic  movements  of  the  neck  and  head  and  sometimes  of 
the  extremities.  In  the  course  of  a  few  months  paralysis  occurs  in  the 
affected  muscles  with  marked  atrophy  and  loss  of  faradic  irritability. 

MYOTONIA. 

Myotonia  Congenita. — Myotonia  congenita  {Thomsens  Disease)  is 
characterized  by  an  inhibition  of  the  voluntary  movements.  This  disturb- 
ance of  movement  is  due  to  a  stiffness  and  tension  of  the  muscles  occur- 
ring at  the  beginning  of  motion.  The  most  important  etiological  factor 
in  the  disease  is  that  it  is  hereditary.  In  almost  every  case  it  begins  in 
early  childhood. 

An  examination  of  sections  of  muscle  taken  from  cases  of  this  dis- 
ease has  shown  an  enormous  hypertrophy  of  all  the  muscular  fibres, 
great  proliferation  of  the  nuclei,  and  a  slight  increase  of  the  perimysium. 
The  disease  appears  to  be  a  congenital  affection  of  the  muscular  fibres. 

Symptoms. — The  symptoms  are  noticed  only  during  voluntary  move- 
ments, the  contraction  of  the  muscles  responding  very  slowly  to  the  will, 
and  persisting  for  a  little  time  after  the  individual  has  willed  the  muscular 
movement  to  cease.  After  a  period  of  quiescence,  the  muscles  become  stiff 
and  respond  to  the  will  only  with  difficulty.  On  repeated  efforts  to  over- 
come this  difficulty  the  same  movement  becomes  more  and  more  easily 
accomplished.  A  tap  upon  the  muscles  causes  a  slow,  tonic  contraction, 
which  relaxes  slowly.  Long-continued  rest,  heat,  cold,  and  excitement 
cause  an  exaggeration  of  the  symptoms.  The  muscles  of  the  arms 
and  legs  are  those  usually  implicated.  Sensation  and  the  reflexes 
are  normal.  The  muscles  are  apparently  enlarged,  giving  at  times 
the  appearance  of  hypertrophy,  but  the  strength  of  the  muscle  is  not 
proportionate  to  its  size.  Erb  has  described  a  characteristic  electrical 
reaction,  called  the  myotonic  reaction,  in  which  the  contractions  caused  by 


942  PEDIATRICS. 

either  current  attain  their  maximum  slowly  and  relax  slowly,  and  wave- 
like contractions  pass  from  the  cathode  to  the  anode. 

Diagnosis. — The  diagnosis  is  made  by  the  characteristic  difficulty  in 
making  volitional  movements,  by  the  peculiar  contraction  which  follows 
a  slight  tap  on  the  muscles,  and  by  the  presence  of  the  myotonic  re- 
action. 

Treatment. — Although  at  times  it  may  recover  temporarily,  the  disease 
is  incurable,  and  there  is  no  known  treatment  which  is  of  much  benefit, 
although  active  exercise  is  indicated  and  is  in  most  cases  desirable. 

Cong-enital  Paramyotonia. — Congenital  paramyotonia  is  a  rare  con- 
dition sometimes  resembling  myotonia  congenita.  It  is  an  hereditary  affec- 
tion characterized  by  tonic  spasms  lasting  from  several  minutes  to  several 
hours  and  coming  on  soon  after  birth.     There  is  no  myotonic  reaction. 

Paramyoclonus  Multiplex  (^myoclonia). — The  principal  symptom  of 
this  condition  is  a  clonic  spasm  of  the  muscles  of  the  extremities,  the  face 
generally  being  exempt.  The  convulsions  occur  at  the  rate  of  sixty  to 
one  hundred  per  minute.  They  are  not  rhythmical.  They  may  be 
disseminated  or  localized,  and  involve  a  single  muscle  or  a  group  of 
muscles  symmetrically  on  both  sides  of  the  body.  The  twitcliings  cease 
during  sleep.  There  is  no  disturbance  of  other  functions  of  the  body, 
and  the  mechanical  and  electrical  reactions  of  the  muscles  are  normal. 
The  attacks  occur  at  intervals.     The  condition  is  very  rare  in  childhood. 

EPILEPSY. 

Epilepsy  is  presumably  an  organic  disease  of  the  nervous  system  in 
which  the  pathological  lesion  has  not  yet  been  determined. 

The  characteristic  symptoms  are  attacks  of  unconsciousness  with  or 
without  convulsions,  with  a  great  liability  to  a  recurrence  of  these  attacks 
through  a  long  period  of  time.  The  transient  loss  of  consciousness  with- 
out convulsions  which  occurs  in  epilepsy  is  called  petit  mal,  while  the  loss 
of  consciousness  with  general  convulsive  manifestations  is  called  grand 
mal.  Convulsions  precisely  similar  to  those  occurring  in  true  epilepsy, 
may  occur  in  organic  cerebral  disease  as  the  result  of  external  trauma- 
tism or  from  other  causes  ;  such  convulsions  have  been  termed  epileptiform. 
The  term  JacJcsonian  epilepsy  is  applied  to  localized  convulsions  which  are 
the  result  of  focal  cerebral  affections.  Such  attacks  are  not  associated 
with  loss  of  consciousness,  are  symptomatic  of  some  form  of  cortical 
irritation  and  are  not  to  be  confounded  with  true  epilepsy. 

It  is  im'portant  that  a  sharp  distinction  should  be  made  between  the 
convulsions  of  true  epilepsy  and  the  many  reflex  convulsive  attacks 
which  come  from  a  variety  of  causes  and  arise  from  the  hypersensitive 
condition  of  the  infant's  nervous  system.  These  reflex  convulsions  so 
closely  resemble  the  convulsions  which  occur  in  epilepsy  that  the  great 
importance  of  distinguishing  between  the  two  diseases  can  hardly  be  ex- 
aggerated.    In  the  infant's  rapidly  growing  brain  the  irritability  of  certain 


DISEASES   OF   THE   NERVOUS   SYSTEM.  943 

motor  centres  is  physiologically  far  greater  than  in  later  childhood  and 
in  adult  life.  This  irritability  is  the  source  of  nervous  explosions  pro- 
duced by  many  causes,  often  slight  in  their  nature,  and  it  is  impossible  to 
differentiate  these  explosions  by  their  clinical  symptoms  alone  from  the 
convulsive  attacks  of  epilepsy.  On  the  other  hand,  we  frequently  see 
convulsions  in  infancy  for  which  no  cause  can  be  found,  which  recur  for  a 
time  and  then  cease,  to  reappear  many  years  later  in  the  form  of  true 
epilepsy. 

Etiology, — It  is  usually  granted  that  the  initial  disturbance  of  true 
epilepsy  originates  somewhere  in  the  cortical  centres  of  the  brain,  and  not 
necessarily  in  the  motor  areas,  and  that  the  epileptiform  convulsion  results 
from  the  liberation  of  energy  from  these  cortical  cells.  True  epilepsy 
may,  of  course,  originate  in  early  infancy,  and  does  so  in  a  large  number 
of  cases.  Whether,  however,  infantile  convulsions  may  be  the  cause  of 
epilepsy  is  a  very  different  question.  The  fact  is  that  we  do  not  as  yet 
know  what  produces  epilepsy.  The  various  etiological  factors  which  are 
usually  cited,  such  as  fright,  injury,  and  dentition,  probably  have  nothing 
more  to  do  with  the  production  of  the  disease  than  to  precipitate  its  de- 
velopment in  an  individual  who  is  already  predisposed  to  it.  The  influ- 
ence of  a  hereditary  neuropathic  predisposition  must  be  admitted,  for  in  a 
large  number  of  cases  there  is  a  history  of  epilepsy  in  the  immediate  or 
near  relatives.  There  is  no  good  reason  for  believing  that  reflex  convul- 
sions in  themselves  ever  lead  to  true  epilepsy. 

Symptoms. — Epilepsy  may  begin  in  infancy  or  at  any  time  throughout 
childhood,  but  a  frequent  time  for  its  development  is  at  puberty. 

Petit  Mai. — The  petit  mal  may  exist  in  different  degrees  of  severity. 
In  the  mildest  form,  which  may  often  pass  unnoticed  unless  the  attendants 
are  especially  on  the  watch  for  it,  the  child  stops  for  a  moment  in  its  occu- 
pation, whether  speaking,  eating,  or  playing,  while  its  eyes  become  fixed, 
the  face  blanches  or  becomes  congested  and  assumes  a  vacant  expression. 
This  condition  may  last  for  only  a  few  seconds,  when  the  child  assumes 
its  former  occupation  as  though  it  had  never  been  interrupted,  and  usually 
is  not  aware  that  anything  has  happened.  In  other  cases  this  condition 
lasts  a  little  longer,  and  slight  twitching  of  the  lower  part  of  the  face  and 
of  the  extremities  may  occur.  Again,  the  attacks  are  more  severe,  the 
child  complains  of  being  dizzy,  staggers,  has  slight  convulsive  movements, 
and  turns  pale,  this  condition  lasting  for  a  minute  or  more,  and  being 
quite  marked,  but  without  any  total  loss  of  consciousness.  Momentary 
attacks  of  staggering  sometimes  occur  alone  in  place  of  the  attacks  above 
described.  At  times  these  attacks  of  petit  mal  are  the  only  manifesta- 
tions of  the  disease,  but  in  severe  cases  they  are  apt  to  be  accom- 
panied by  occasional  attacks  of  grand  mal.  They  may  occur  as  often 
as  twenty  or  thirty  times  a  day,  or,  on  the  other  hand,  they  may  be 
noticed  only  once  in  four  or  five  days,  and  sometinies  they  are  absent  for 
longer  intervals. 


944  PEDIATRICS. 

Grand  Mai. — In  the  grand  mal  the  attacks  are  of  much  greater 
severity.  Tliey  are  sometimes  preceded  for  several  hours  by  a  feehng 
of  malaise  or  general  discomfort,  but  this  is  not  always  present.  Patients 
sometimes  have  notice  of  the  sudden  onset  of  the  attack,  which  imme- 
diately preceding  the  convulsions  and  forming  part  of  the  attack  itself 
is  called  the  aiira.  This  aura  may  be  of  different  kinds.  It  is  most  com- 
monly a  sense  of  fulness  or  oppression  in  the  epigastrium,  from  which 
something  seems  to  rise  into  the  throat,  and  unconsciousness  supervenes. 
It  may  be,  however,  a  pain  or  a  sensation  of  numbness,  tingling,  or  other 
form  of  pamesthesia  m  various  parts  of  the  body.  Sometimes  tinnitus  is 
the  first  symptom.  Frequently  the  patient  has  no  warning  whatever  of 
the  attack,  but  falls  unconscious  with  or  without  a  cry.  The  face  becomes 
congested,  and  the  eyes  usually  turn  upward  so  that  only  the  whites  can 
be  seen.  After  this  follows  the  stage  of  tonic  convulsions,  which  is  some- 
times so  short  that  it  is  overlooked.  Then  come  the  clonic  convulsions, 
which  in  typical  cases  are  general,  although  the  limbs  on  one  side  of  the 
body  are  sometimes  more  affected  than  those  on  the  other  side.  In  such 
cases  a  post-epileptic  hemiplegia  lasting  several  hours  or  days  may 
result.  The  movements  of  the  limbs  are  apt  to  be  very  violent,  the  hands 
are  clinched,  the  thumbs  being  flexed  on  the  palms  and  the  fingers  closed 
over  them.  In  many  cases  the  patients  froth  at  the  mouth.  In  the  more 
severe  cases  the  children  bite  their  tongues  and  pass  their  urine  involun- 
tarily. The  duration  of  such  attacks  is  usually  five  or  ten  minutes,  but 
one  attack  may  succeed  another  mth  little  or  no  intermission.  When  the 
attacks  follow  one  another  in  this  way  for  several  hours  the  patient  is  said 
to  be  in  the  epileptic  status,  and  his  condition  as  regards  life  is  very  serious. 
After  the  convulsion  ceases  the  child's  breathing  becomes  stertorous  and 
the  limbs  are  relaxed.  Later,  and  before  consciousness  fully  returns,  the 
child  often  falls  into  a  deep  sleep,  and'  on  waking  has  no  recollection  of 
the  attack,  but  complains  only  of  headache  and  of  mental  confusion. 
Attacks  often  occur  in  the  night,  and  in  this  ^vay  may  be  overlooked,  the 
only  evidence  of  them  being  that  the  child  has  wet  the  bed.  In  certain 
cases,  wiien  only  nocturnal  attacks  have  been  present,  we  often  have 
reason  to  believe  that  the  disease  has  existed  for  considerable  periods 
before  its  jDresence  was  suspected.  In  some  cases  in  connection  with 
the  attacks  there  is  a  desire  to  walk  or  to  run,  so  that  the  patient  must 
be  closely  watched.  In  this  condition  children  may  walk  straight  against 
an  obstacle,  though  they  are  more  apt  to  stop  when  something  comes 
across  their  path.     Sometimes  they  Avalk  or  run  in  circles. 

The  cases  of  paroxysmal  running  described  by  Bullard  are  at  times 
the  early  manifestations  of  an  epilepsy  Avhich  will  develop  later,  although 
they  may  also  be  only  the  symptoms  of  hysteria,  chorea,  and  organic 
cerebral  cUsease. 

In  the  so-called  massed  form  of  epilepsy  the  convulsions  occur  at 
frec|uent  and  at  very  short  intervals,  then  cease  suddenly  only  to  recur 


DISEASES    OF  THE    NERVOUS    SYSTEM.  945 

again  after  an  interval  of  many  months  in  the  same  massed  form.  In  later 
life  the  attacks  eventually  become  more  evenly  distributed  and  assume  the 
usual  type  of  grand  mal.  This  variety  is  very  atypical  in  the  beginning 
and  may  give  rise  to  a  suspicion  of  hysteria.  It  is  peculiarly  resistent  to 
treatment. 

Epileptic  children  are  liable  to  bursts  of  ungovernable  anger  and  vio- 
lence lasting  for  hours,  in  which  they  may  tear  and  destroy  things,  bite 
the  mother  or  nurse,  and  are  apparently  for  a  time  under  the  influence  of 
illusions  and  hallucinations.  This  form  is  called  ^j.s^c/h'c  epilejisy  in  dis- 
tinction to  motor  epilepsy,  and  is  due  to  the  nervous  explosion  taking 
place  in  the  psychic  instead  of  the  motor  areas.  The  motor  attack  may 
precede  the  psychic,  or  vice  versa. 

The  condition  of  patients  between  the  attacks  is  in  the  lighter  cases 
and  in  the  beginning  of  the  disease  usually  quite  normal.  As  the  disease 
progresses,  however,  there  is  a  tendency  to  mental  impairment,  and  in  the 
more  severe  cases,  in  contrast  to  the  lighter  ones,  we  are  apt  to  find  some 
enfeeblement  of  intellect,  which  at  times  may  go  on  to  an  advanced 
dementia.  Such  cases  are  to  be  distinguished  from  the  symptomatic 
epilepsy  seen  in  cases  of  defective  mental  development. 

Diagnosis. — As  the  convulsive  attacks  occurring  in  epilepsy  cannot  be 
distinguished  clinically  from  similar  attacks  due  to  other  causes,  we  are 
forced  to  differentiate  epilepsy  from  other  diseases  by  carefully  eliminating 
other  causes  for  the  convulsions.  We  must  also  wait  to  see  whether  the 
attacks  will  continue  indefinitely,  in  which  case  they  are  more  likely  to  be 
epileptic. 

The  diagnosis  of  epilepsy  is  made  from  a  continuance  of  the  attacks 
after  a  considerable  period  without  evidence  of  any  organic  disease  or 
reflex  irritation.  When  the  child  bites  its  tongue  during  the  attack  and 
goes  to  sleep  after  the  convulsion,  or  when  there  is  temporarj^  mental 
impairment  after  the  convulsion,  we  have  good  reason  to  state  that  the 
convulsions  are  due  to  true  epilepsy,  especially  if  no  symptoms  of  organic 
brain  disease  coexist. 

Epileptic  are  easily  distuiguished  from  hysterical  convulsions  by  the 
presence  of  consciousness  in  the  latter,  at  any  rate  to  a  considerable 
extent.  Hysterical  convulsions  in  cliildren  are  not  very  common,  and 
almost  never  exist  without  the  presence  of  other  s^nnptoms  of  hysteria. 

Prognosis. — The  prognosis  of  epilepsy  for  life  is.  on  the  whole,  favor- 
able, and  epileptics  may  live  for  many  years. 

As  regards  cure,  the  prognosis  in  cases  beginning  in  early  infancy  is 
very  serious  but  by  no  means  hopeless.  When  the  disease  begins  at  the 
ao-e  of  ten  years  or  later  a  certain  number  seem  to  recover,  at  least  tem- 
porarily. Many  authorities  consider  that  true  epilepsy  is  never  cured,  yet 
undoubted  cases  exist  in  which  no  convulsions  take  place  for  years. 

The  prognosis  is  influenced  by  the  length  of  time  the  disease  has  run 
before  thorough  treatment  is  instituted.     If  begun  early  and  carried  out 

60 


946  PEDIATRICS. 

systematically  for  months  or  years,  according  to  the  severity  of  the  case, 
the  chances  of  complete  recovery  are  greatly  increased.  Death  may 
occur  from  accidents  during  an  attack,  such  as  falls,  from  being  smoth- 
ered in  bed  or  drowned  while  bathing. 

Treatment. — The  child  should  be  treated  at  once,  in  order  to  avoid 
continuous  shocks  to  its  nerve-centres.  Much  benefit  results  from  early 
attention  to  general  hygienic  conditions  and  to  protection  from  nervous 
disturbances.  The  management  of  these  cases  demands  constant  watch- 
fulness and  tact,  so  as  to  regulate  the  surroundings  of  the  child  in  such  a 
way  as  to  avoid  all  source  of  nervous  excitement  and  irritation,  such  as 
arise  from  improper  diet,  gastric  and  intestinal  disorders,  genital  irrita- 
tion, and  adenoid  growths.  The  diet  must  be  regulated  according  to  the 
especial  indications  for  each  patient.  A  slight  gastric  irritation  apparently 
produces  more  serious  consequences  in  epilepsy  than  irritation  of  any 
other  part  of  the  body.  A  vegetable  diet  is  usually  indicated,  but  when 
the  child  does  not  thrive  on  tliis  it  is  adnsable  to  give  a  certain  amount  of 
meat.     Eggs  are  usually  well  borne. 

The  bromides  in  some  form  are  the  most  useful  drugs.  At  present 
there  is  a  reaction  against  the  absolute  exclusion  of  nitrogenous  food.  It 
should,  however,  be  given  in  Imiited  quantities.  Of  far  more  importance 
is  the  diminution  or  exclusion  of  chlorides,  especially  table  salt  from  the 
food.  It  has  been  demonstrated  experimentally  and  clinically  that 
bromides  exert  a  much  more  beneficial  action  when  chlorides  are 
excluded  and  considerably  smaller  doses  are  required  to  produce  the 
same  effect.  The  untoward  results  of  the  bromides  are  also  less  likely  to 
develop.  In  severe  cases  sodium  bromide  may  replace  the  salt  in  cooked 
food  and  be  used  at  the  table.  One  drachm  to  one  loaf  of  bread  is  the 
amount  usually  used.  "WTien  such  substitution  is  made  it  is  important  to 
keep  an  accurate  record  of  the  amount  of  bromide  administered  in  this 
form.  Tourette  has  suggested  a  very  efficient  combination  in  the  propor- 
tion of  two  parts  of  potassium  bromide  to  one  part  each  of  sodium 
bromide,  ammonium  bromide  and  sodium  benzoate.  It  is  best  to  begin 
with  a  dose  of  0.36  gramme  (6  grains)  three  times  a  day  for  infants  of  one 
to  two  years,  and  to  double  this  amount  for  older  children.  If  the  con- 
vulsions are  not  controlled,  the  doses  should  be  increased  gradually  until 
the  physiological  action  of  the  drug  is  noticed.  This  treatment  should  be 
carried  out  for  long  periods,  but  under  constant  supervision,  and  from  six 
months  to  a  year  after  the  convulsive  attacks  seem  to  have  ceased.  Cases 
due  to  tramnatic  or  organic  lesions  are  occasionally  benefited  by  opera- 
tion.    They  are  less  susceptible  to  bromide  treatment. 

The  following  case  represents  epilepsy  in  a  girl  three  years  old  : 

She  was  healthy  at  birth,  and  remained  so  until  she  was  two  months  old.  At 
that  time  she  began  to  have  slight  convulsive  attacks,  the  cause  of  which  could  not  be 
accounted  for.  During  the  earlier  attacks  she  appeared  to  be  frightened.  She  would 
tien  scream,  and  become  rigid  and  unconscious  for  about  fifteen  minutes,  after  which 


DISEASES   OF   THE   NERVOUS   SYSTEM.  947 

she  would  sleep  three  or  four  hours.  These  attacks  occurred  at  all  hours  of  the  day 
and  of  the  night.  They  continued  at  irregular  intervals,  but  were  not  so  frequent  after 
the  first  year  and  a  half.  During  the  first  year  she  seemed  as  bright  as  any  infant  of 
her  age,  and  developed  normally.  She  was  treated  with  the  bromides,  and  they  seem 
to  have  been  of  some  benefit,  but  did  not  produce  a  permanent  cure. 

In  the  third  year  her  mental  condition  was  much  affected.  She  had  never  been 
able  to  sit  alone  or  to  bear  her  weight  on  her  feet.  She  could  not  feed  herself,  and  she 
understood  very  little  that  was  said  to  her.  Her  head  was  about  the  normal  size. 
Her  face  and  eyes  had  a  vacant  expression,  and  she  had  to  be  taken  care  of  as  though 
she  were  an  infant  in  the  early  months  of  life. 

In  this  case  there  was  jio  history  of  epilepsy  or  of  any  especial  nervous  disorder  in 
the  family,  nor  of  traumatism  or  of  any  serious  disease  which  could  have  produced  this 
nervous  disturbance.  It  was  a  case  of  epilepsy  starting  from  some  unkno^vn  cause  and 
resulting  in  permanent  idiocy. 

The  following  case  illustrating  the  psychic  form  of  epilepsy  occurred 
in  the  practice  of  Dr.  George  A.  Waterman  : 

L.  H.,  a  girl,  was  delicate  as  an  infant.  At  the  age  of  2  J  years  she  had  convul- 
sions and  for  two  days  ether  was  used  freely  to  control  them.  At  4  and  6  years  similar 
attacks  occurred  which  were  attributed  to  indiscretions  of  diet.  Since  the  age  of  5, 
she  was  subject  to  attacks  of  abdominal  pain,  lasting  about  one  minute,  during  which 
she  screamed,  pressed  her  hands  into  the  abdomen,  flushed  in  the  face  and  seemed 
about  to  fall.  The  attacks  terminated  with  the  passage  of  gas.  They  came  often 
several  times  a  day  or  diu-ing  sleep.  There  were  intervals  of  one  or  two  weeks  when 
they  did  not  occur.  At  the  age  of  11  years  the  attacks  assumed  a  different  character, 
which  in  general  were  as  follows  :  She  suddenly  sat  up  in  bed  ;  opened  her  eyes  as  if 
awakening  but  the  expression  was  fixed  and  glistening,  the  pupils  dilated,  the  lips 
parted  showing  the  teeth  and  giving  an  expression  of  ecstacy.  Her  eyes  appeared  to 
follow  some  object  moving  about  in  the  air.  The  grin  then  disappeared  leaving  a 
vacant  expression  and  she  fell  back  in  a  condition  of  stupor  from  which  she  could  be 
aroused  after  a  few  minutes  but  retained  no  knowledge  of  what  had  happened.  The 
attacks  occurred  once  or  twice  a  night  and  lasted  several  years.  She  improved  very 
much  under  a  rigid  bromide  treatment  for  a  considerable  period  and  then  the  massed 
form  of  epilepsy  developed. 

Instances  of  mania  and  melancholia  at  times  occur.  Hallucinations, 
which  are  a  common  symptom  in  the  insanity  of  adults,  occm-  in  children 
usually  in  connection  with  the  delirium  of  fever,  or  more  rarely  ^vith 
epilepsy.  Insanity  is  met  with  in  children  at  any  age  ;  it  is  extremely  rare 
before  puberty,  but  then  becomes  more  frec|uent.  The  subject  is  more 
appropriately  treated  in  text-books  on  nervous  and  mental  diseases  and 
one  may  especially  recommend  the  last  edition  of  Church  and  Peterson. 

IDIOCY.— IMBEdLITY. 

Idiocy  is  a  condition  in  which  there  is  a  complete  and  permanent  im- 
pairment of  the  mind.  Imbecility  or  retarded  mental  development  is  a 
slio-hter  grade  of  mental  deficiency.  Both  conditions  occur  in  brains 
which  are  not  fully  developed  in  contradistinction  to  dementia,  in  which 
the  faculties  are  lost  in  a  fully  developed  brain. 


948 


PEDIATRi<CS. 


Etiology. — Idiocy  may  be  congenital,  arising  from  intra-uterine  dis- 
ease, or  it  may  be  hereditary  in  families  in  whom  the  parents  have  had 
such  nervous  manifestations  as  insanity,  hysteria,  epilepsy,  and  chorea,  or 
who  have  been  syphilitic,  alcoholic,  or  consanguineous.  The  acquired  form 
may  be  caused  when  there  is  a  predisposition  to  mental  disease  or  to  a 
cerebral  lesion  produced  by  traumatic  conditions,  such  as  pressure  on  the 
head  at  birth,  injury  to  the  head  by  falls  or  blows,  and  intracranial  liemor- 

Fm.  192. 


Microcephalic  idiot,  10  years  old. 


rhages.  Idiocy  is  in  some  cases  also  associated  with  hydrocephalus  and 
microcephalus ;  it  may  also  be  a  result  of  epilepsy,  especially  when  the 
epilepsy  develops  early  in  life  and  the  attacks  are  frequent.  Acute  infec- 
tious diseases,  especially  epidemic  cerebro- spinal  meningitis  and  acute 
encephalitis,  are  often  responsible  for  the  development  of  idiocy. 

Pathological  Anatomy. — Idiocy  is  rarely  a  primary  disease,  but  usually 
presents  the  terminal  lesions  of  many  different  diseases  of  the  brain.    The 


DISEASES   OF  THE   NERVOUS   SYSTEM.  949 

result  of  these  pathological  conditions  is  usually  atrophy,  which  may  be 
local  or  general,  and  of  intra-  or  extra-uterine  origin.  Various  congenital 
deformities,  or  stigmata  of  degeneration,  as  those  of  the  lips,  palate,  mouth, 
hands,  and  feet,  are  frequently  associated  with  idiocy,  such  as  hare-lip, 
cleft  palate,  strabismus,  ears  of  abnormal  shape  or  deficient  markings, 
polydactylism,  malformation  of  the  teeth,  coloboma,  macrocephalism, 
microcephalism,  marked  facial  asymmetry,  spina  bifida,  malformation  of 
the  genital  organs,  congenital  absence  of  hair,  infantilism,  feminism  and 
mascuhnism.  Many  other  anomahes  of  development  are  noted,  but  too 
much  importance  should  not  be  attached  merely  to  these  stigmata  as  many 
of  them  may  occur  in  children  w^ho  are  mentally  sound. 

Symptoms. — The  symptoms  of  idiocy  vary  according  as  the  individual 
represents  a  high  or  a  low  grade  of  this  condition.  An  idiot  may  have  a 
large  head  from  hydrocephalus,  or  a  small  head  from  cerebral  non- 
development  or  from  cerebral  atrophy.  Again,  idiots  may  have  normally 
developed  crania  both  as  to  size  and  as  to  shape.  In  the  loAver  grades 
there  is  often  some  physical  malformation  in  connection  with  the  men- 
tal impairment.  The  temperament  may  be  violent  or  good-natured,  the 
mood  often  alternating.  The  sense  of  morality  is  wholly  lost.  Extreme 
mischievousness  or  even  cruelty  to  animals  and  other  children  may 
be  an  early  indication  of  the  perverted  nature  of  the  child.  In  the 
more  severe  cases  of  idiocy  there  is  considerable  incoordination  of  the 
limbs,  and  the  movements  of  the  child  are  awkward  and  irregular.  In 
many  cases  the  speech  is  almost  unintelligible.  The  idiot  does  not  take 
notice  of  surrounding  objects  as  does  the  normal  child,  and  even  when 
the  sight  and  hearing  are  perfectly  normal  the  impressions  made  on 
the  senses  are  deadened.  Epileptiform  convulsions  very  commonly  ac- 
company idiocy,  and  play  a  most  important  part  in  the  general  condition 
of  the   patient. 

The  symptoms  which  are  usually  met  with,  and  which  enable  us  to 
diagnosticate  a  pronounced  case  of  idiocy,  are  the  characteristic  expres- 
sion, the  occasional  presence  of  strabismus,  the  drooping  head,  the  drool- 
ing, and  the  lack  of  all  idea  of  cleanliness.  The  teeth  are  usually  decayed. 
Sometimes  the  child  is  so  hmp  that  he  is  unable  to  bear  his  weight  at 
all,  or  will  stand  held  by  the  hands,  with  his  feet  apart,  his  knees  bent, 
and  his  trunk  leaning  forward.  The  whole  body  sways  to  and  fro  with 
an  oscillating  movement  and  absence  of  equilibrium.  When  able  to 
walk  alone  he  walks  in  a  staggering,  uncertain  way,  and  falls  easily. 
In  many  cases,  however,  the  child  cannot  even  sit  up  alone.  The  mus- 
cles of  the  neck  are  often  so  weak  that  the  head  falls  over  on  one 
shoulder  or  forward  on  the  chest.  The  vertebral  column  fails  to  sup- 
port the  trunk  and  bends  to  a  marked  degree,  and  all  the  muscles  are 
feeble  and  comparatively  useless.  Lack  of  power  of  attention  and  lack 
of  memory  exist  in  all  cases,  and  in  the  higher  grades  are  often  the  most 
prominent  symptoms. 


950  PEDIATRICS. 

A  special  type  of  idiocy  has  been  described  under  the  term  agenesis 
corticalk,  in  which  the  size  and  weight  of  the  brain  are  normal,  but  in 
which  abnormalities  of  development  of  the  fissures  of  Rolando,  of  the 
interparietal  fissures,  and  of  the  cortical  nerve-cells  have  been  recognized. 
This  form  of  idiocy  is  associated  with  blindness  and  terminates  in 
marasmus. 

Mongolian  idiocy  is  simply  a  type  characterized  by  the  signs  and 
symptoms  of  idiocy  in  cases  in  which  the  nose  is  broad  and  flat  and  the 
palpebral  fissures  slant  downward  toward  the  median  line. 

Another  form  of  idiocy  has  been  described  originally  by  Sachs  and 
repeatedly  observed  by  others,  called  amaurotic  family  idiocy.  This  type 
occurs  for  the  most  part  in  Jewish  families.  Its  chief  characteristics  are 
idiocy  combined  with  spastic  paralysis  of  all  four  extremities,  blindness 
from  optic  atrophy,  and  the  macula  lutea  assumes  a  cherry  red  color.  It 
appears  at  about  eight  to  ten  months  of  age,  and  while  formerly  con- 
sidered as  a  congenital  disease,  is  according  to  pathological  flndings  classed 
as  a  degenerative  disease.     Children  so  affected  die  early  in  life. 

Diagnosis. — We  should  be  careful  in  very  young  children  not  to  con- 
fuse slow  or  retarded  mental  development  with  idiocy.  There  is  so  much 
variation  in  the  time  at  which  children  walk  and  talk,  and  a  delayed  de- 
velopment of  these  functions  must  not  be  considered  to  represent  a  con- 
dition of  mental  impairment.  Some  children  develop  so  slowly,  both 
bodily  and  mentally,  that  they  appear  very  backward  in  comparison  with 
others  of  the  same  age.  Children  in  the  first  year  of  their  hves  may  be 
so  seriously  affected  by  some  grave  disease  that  their  development  is  pre- 
vented from  advancing  normally,  and  in  comparison  with  other  children 
of  the  same  age  they  may  be  far  below  the  usual  grade  of  intelligence.  If, 
however,  we  examine  this  class  of  cases  carefully,  we  see  that,  although 
they  are  very  backward  in  their  development,  they  are  gradually  devel- 
__oping,  and  that  they  do  not  represent  the  condition  of  complete  arrest  of 
development  which  exists  in  idiots. 

It  is  well  to  remember  that  in  rhachitis  and  in  extreme  cases  of  mal- 
nutrition we  are  apt  to  have  not  only  retarded  mental  development,  but  a 
weakness  of  the  extremities  simulating  paralysis.  When  both  these 
conditions  occur,  such  cases  may  sometimes  be  mistaken  for  idiots. 

In  judging  the  mental  development  of  a  given  child  in  reference  to  its 
age  one  will  find  the  following  summary  of  the  normal  state  of  develop- 
ment in  the  early  months  of  life  very  helpful.  It  is  taken  from  Church 
and  Peterson's  "Nervous  and  Mental  Diseases,"  and  was  abstracted  by 
them  from  Fryer's,  "The  Mind  of  the  Child"- 


First  Month.  Sensitive  to  light  as  early  as  first  and  second  days.  Pleasure  in 
light  of  candle  and  in  bright  objects  on  eleventh  day.  Hears  on  fourth  day.  Discrimi= 
nates  sounds  last  two  weeks  of  month.  Starts  at  gentle  touches  second  and  third  days. 
Sensibility   to   taste   about   end  of  first  week.     Strong-smelling   substances  produce 


DISEASES    OF    THE    XERY0U5    SYSTEM.  951 

mimetic  movements  at  birth.  Pleasure  first  days  in  nursing,  in  bath,  in  sight  of 
objects.  Discomfort  first  days  from  cold,  wet,  hunger,  tight  clothing.  Smiles  on 
twenty-sixth  day.  Tears  on  twenty-third  day.  Vowel-sounds  in  fii-st  month.  Memory 
first  active  as  to  taste  and  smell :  then  as  to  touch,  sight,  hearing.  Incoordinate 
movements  of  eyes.  Sleeps  two  hours  at  a  time,  and  sixteen  hours  in  twenty-four. 
Reflexes  active. 

Second  Month. — Strabismus  occasionally  until  end  of  month.  Recognizes  human 
voices  :  turns  head  toward  sounds.  Pleased  with  music  and  with  human  face.  Sleeps 
three,  sometimes  five  or  six  hours.  Laughs  from  tickling  at  eighth  week.  Clasps  with 
its  four  fingers  at  eighth  week.  First  consonants  from  forty-third  to  fifty-first  days 
(am-ma,  ta-hu,  go,  ara). 

Third  Month. — Sixty-first  day,  cry  of  joy  at  sight  of  mother  and  father  :  eyelids 
not  completely  raised  when  child  looks  up.  Accomodates  at  ninth  week.  Notes  sound 
of  watch  at  ninth  week  :  listens  with  attention. 

Fourth  Month. — Eye-movements  perfect.  Objects  seized  are  moved  toward  the 
eyes.  Grasps  at  objects  too  distant.  Joy  at  seeing  self  in  mirror.  Contraposition  of 
thumb  in  grasping  at  fourteenth  week.  Head  held  up  permanently.  Sits  up  with  back 
supported  at  fourteenth  week.     Beginning  to  imitate. 

Fifth  Month. — Discriminates  strangers.     Looks  inquiringly,  pleasure  in  crumpling 
and  tearing  newspapers,  pulling  hair,  ringing  a  bell.     Sleeps  ten  to  eleven  hours  with-  ' 
out  food.     Desire  shown  by  stretching  out  arms.     Seizes  and  carries  objects  to  mouth. 
Consonants  1  and  k. 

Sixth  Month. — Raises  self  to  sitting  posture.  Laughs,  and  raises  and  drops  arms 
when  pleasure  is  great.  -'Crows"  with  pleasure.  Compares  image  of  father  in 
mirror  with  original. 

Seventh  Month. — Astonishment  shown  by  open  mouth  and  eyes.  Recognizes  nurse 
after  four  weeks'  absence.  Sighs.  Imitates  movements  of  head,  of  pursing  lips. 
Averts  head  as  a  sign  of  refusal.     Places  himself  upright  on  lap. 

Eighth  Month. — Astonishment  at  new  sounds  and  sights  :  at  imitations  of  cries  of 
animals. 

Ninth  Month. — Stands  on  feet  without  support.  More  interest  shown  in  things  in 
general.  Strikes  hands  together  with  joy.  Shuts  eyes  and  turns  head  away  when 
something  disagreeable  is  to  be  endured.  Fear  of  dog.  Turns  over  when  laid  face 
downward.  Turns  head  to  light  when  asked  where  it  is.  Questions  understood 
before  child  can  speak.     Voice  more  modulated. 

'  Tenth  Month. — Sits  up  without  support  in  bath  and  carriage.  First  attempts  at 
walkinc'  at  forty-first  week.  Beckoning  imitated.  Missed  parents  in  absence,  also  a 
sinsle  nine-pin  of  a  set.  Cannot  repeat  a  syllable  heard.  Monologues  and  hints  at 
imitation  (ma,  pappa,  tatta,  appapa,  baba,  tata,  pa,  rrrr,  rrra). 

Eleventh  Month. — ^Screaming  quieted  by  "sh."  Sittmg  becomes  habit  for  life. 
Stands  without  support.  Stamps.  Syllable  correctly  repeated.  Whispering  begins. 
Consonants  h,  p,  t,  d.  m,  n.  r.  1.  g,  k,  vowel  a  most  used,  u  and  o  rare,  i  very  rare. 

Twelfth  Month. — Pushes  chair.  Can  not  raise  self  or  walk  without  help.  Obeys 
command.     Gives  the  hand. 

Thirteenth  Month. — Creeps.  Shakes  head  in  denial.  Says  papa  and  mamma. 
Understands  some  words  spoken. 

Fourteenth  Month. — Can  not  walk  without  support.  Raises  himself  by  chair. 
Imitates  coughing  and  swinging  of  arms. 

Fifteenth   J/oniJA.— Walks  without   support.     Laughs,    smiles,    gives    a   kiss    on 
request.     Repeats  syllables.     Understands  ten  words. 
Sixteenth  Month.— Vmxis  alone.     Falls  rarely. 

Seventeenth,  Eighteenth,  and  Nineteenth  Months.— S\eei>s  ten  hours  at  a  time. 
Associates  words  with  objects  and  movements.     Blows  horn,  strikes  with  hand  or  foot, 


952  PEDIATRICS. 

gives  leaves  to  stag,  waters  flowers,  puts  stick  of  wood  in  stove,  washes  hands,  combs 
and  brushes  hair,  and  other  imitative  movements. 

Twentieth  to  Twenty-fourth  Months. — Marks  with  pencil  on  paper,  whispers  in 
reading  newspaper.  Very  few  expressions  of  his  are  recognizable.  Executes  orders 
with  surprising  accuracy.     Tries  to  sing  and  beat  time  and  dance. 

Twenty-fifth  to  Thirtieth  Month. — Distinguishes  color  correctly.  Sentences  of  sev- 
eral words.     Begins  to  climb  and  jump  and  to  ask  questions. 

Thirtieth  to  Fortieth  Month. — Goes  up-stairs  without  help.  Sentences  correctly 
applied.  Clauses  formed.  Words  distinctly  spoken,  but  influence  of  di-alect  appears. 
Questioning  repeated  to  weariness.  Approximates  manner  of  speech  to  that  of  family 
more  and  more. 

Treatment. — The  treatment  of  idiots  is  essentially  comprised  under 
the  question  of  their  education.  The  education  of  this  class  of  cases 
should  be  begun  early,  usually  from  the  fourth  to  the  sixth  year.  Much 
can  be  done  to  improve  the  various  defects  which  exist  in  each  individual. 
He  can  usually  be  taught  to  co-ordinate  his  movements,  and  by  attencting 
to  his  general  health  his  physical  condition  can  often  be  much  improved. 
In  many  cases,  if  convulsions  are  present,  they  can  be  more  or  less  con- 
trolled. Malformations  or  paralyses  can  be  treated  with  benefit  by  appa- 
ratus or  by  operation.  The  best  results  in  these  cases  will  be  attained 
by  placing  the  children  in  institutions  devoted  to  the  training  of  idiots. 
For  an  excellent  outline  of  the  methods  employed  to  educate  idiots  and 
imbeciles,  the  reader  is  referred  to  the  1905  edition  of  Church  and 
Peterson,  "  Nervous  and  Mental  Diseases."  Parents  can  be  told  that  the 
association  of  their  children  with  others  who  are  feeble-minded  is  not 
a  disadvantage,  while  it  is  often  a  great  disadvantage  for  the  children  of 
sound  mind  in  a  family  to  be  associated  with  one  who'is  idiotic.  In  the 
large  majority  of  cases,  however,  they  will  always  have  to  be  supervised 
during  their  lives,  and,  in  most  instances,  after  they  have  advanced  to  a 
certain  point  they  are  liable  to  retrograde. 

ARRESTED   PSYCHICAL  DEVELOPMENT. 

Arrested  psychical  development  is  a  term  used  in  speaking  of  an  ap- 
parent lack  of  mental  growth  which  is  sometimes  met  with  in  infancy. 
So  far  as  we  know,  it  is  a  functional  and  not  an  organic  condition  of  the 
brain.  Infants  with  this  affection  develop  both  mentally  and  physically 
for  a  variable  period,  perhaps  five  or  six  months,  and  then  continue  to 
develop  physically  but  cease  to  develop  mentally.  This  condition  lasts 
for  a  variable  period  of  months,  when  their  mental  development  begins 
again,  and,  although  for  some  time  they  are  backward  in  comparison  with 
other  children  of  their  age,  they  finally  show  no  trace  of  an  abnormal 
mental  condition. 

In  some  cases  the  arrest  of  cerebral  development  is  associated  with  a 
condition  of,  physical  weakness,  so  that  the  power  to  sit  and  to  walk  at  the 
usual  age  is  delayed  to  a  much  later  period,  as  the  third  or  fourth  year. 

Arrested  psychical  development  seems  to  be  rather  commonly  asso- 


DISEASES   OF   THE   NERVOUS   SYSTEM.  953 

dated  with  rhachitis,  and  may  also  occur  in  the  course  of  severe  illnesses, 
but  nothing  else  is  definitely  known  concerning  it. 

RETARDED   SPEECH. 

When  during  the  second  year  the  power  of  speech  does  not  develop 
with  the  usual  rapidity,  it  is  spoken  of  as  retarded  speech. 

This  lack  of  power  to  speak  may  be  from  a  simple  lack  of  develop- 
ment of  certain  portions  of  the  brain,  or  from  organic  or  functional  cere- 
bral disturbance.  It  may  also  arise  from  abnormal  conditions  outside  of 
the  brain.  The  cases  which  are  caused  by  a  lack  of  development  may 
be  of  congenital  origin,  or  may  be  due  to  an  arrested  cerebral  develop- 
ment produced  by  a  number  of  causes.  These  causes  are  usually  con- 
aected  with  some  serious  interference  with  the  cerebral  growth,  such  as 
defective  development  of  the  bulbar  nuclei.  Organic  aphasia  is  like  that 
produced  by  some  organic  lesion  of  the  brain  such  as  exists  in  cases  of 
cerebral  paralysis.  It  may  also  be  connected  with  the  condition  of  idiocy. 
The  functional  aphasia  has  already  been  described.  It  may  be  produced 
by  many  causes,  among  others  the  infectious  diseases.  A  child  may  for  a 
time  during  a  severe  illness,  and  after  convalescence  has  been  established, 
apparently  be  miable  to  use  the  words  that  it  was  accustomed  to  before 
the  illness.  We  have,  however,  in  a  number  of  cases,  noticed  that  the 
child  speaks  better  than  it  did  before  the  illness. 

Retarded  speech  may  also  be  caused  by  such  physical  defects  as  dis- 
ease of  the  ear  resulting  in  deafness,  and  from  such  a  physical  malforma- 
tion of  the  mouth,  palate,  or  vocal  cords  as  to  render  articulation  impossible. 
In  this  connection  stammering  may  be  spoken  of  as  a  cause  of  retarded 
speech.  When  called  upon  to  decide  why  the  child  is  unable  to  speak, 
the  previous  history  should  be  carefully  investigated.  In  this  way  organic 
disease  of  the  brain  can  be  eliminated  by  means  of  the  absence  of  the 
usual  symptoms  of  such  disease,  especially  hemiplegia,  and  by  ascertain- 
ing that  the  child  has  not  had  any  disease  sufficiently  severe  in  its  char- 
acter to  interfere  with  the  development  of  the  centres  of  speech.  After 
determining  that  the  child  is  not  an  idiot,  the  ear  and  mouth  should  be 
examined.  If  the  child  is  deaf,  there  is  a  good  reason  for  his  not  being 
able  to  speak.  Even  when  young  children  have  learned  to  speak  fairly 
well,  if  they  later  become  deaf  from  a  disease  like  scarlet  fever,  they  are 
very  apt  to  become  mute  also.  When  a  lesion  of  the  ear  has  occuiTed 
before  the  child  has  learned  to  speak,  he  almost  invariably  is  found  to  be 
a  deaf-mute,  although  there  may  be  no  defects  in  articulation  or  in  his 
mental  condition.  It  is  seldom  that  any  defect  in  the  mouth  or  throat  is 
found  which  interferes  ^^^th  articulation,  except  in  cases  in  which  verj- 
extensive  lesions  are  present,  such  as  cleft  palate,  and  sometimes  enlai^-ed 
tonsils  combmed  with  a  high-arched  palate  and  a  large  adenoid  growth. 
The  tongue-tie  which  the  parents  usually  consider  to  be  the  cause  of 
the  retarded  speech  is  seldom  present.     When  no  symptom  of  organic, 


954  PEDIATRICS. 

functional,  or  developmental  cerebral  disease  exists,  when  there  is  no 
physical  deformity,  and  when  the  child  hears  well  and  seems  bright  and 
well  developed  in  other  ways,  the  parents,  as  a  rule,  may  be  assured  that 
the  speech  is  merely  retarded  and  will  probably  develop  later. 

MICROCEPHAT.US. 

When  the  head  is  under  a  certain  size  it  is  called  microcephalic.  The 
size  which  is  usually  accepted  as  representing  a  microcephalic  head  is 
from  40.5  to  43  cm.  (16  to  17  inches).  According  to  Broca,  microcepha- 
lus  exists  when  the  brain  weighs  1049  grammes  (35  ounces)  in  the  male, 
and  907  grammes  (30  ounces)  in  the  female.  It  is  generally  considered 
that  this  microcephalic  condition  is  due  to  a  lack  of  intra-cranial  pressure. 
Together  with  the  lack  of  development  of  the  cranial  bones  there  exists 
in  these  cases  a  lack  of  development  or  atrophy  of  the  brain,  which  may 
be  considered  either  as  the  cause  of  the  lack  of  intra-cranial  pressure  or, 
as  is  still  believed  by  some  writers,  as  the  result  of  the  external  pressure 
caused  by  a  premature  synostosis.  Microcephalic  children  are  feeble- 
minded and  usually  present  the  symptoms  of  a  somewhat  low  grade  of 
idiocy.  They  not  infrequently  show  signs  of  weakness  of  the  limbs.  Oper- 
ative measures  for  the  removal  of  portions  of  the  skull  to  encourage  its 
growth  are  unavailing.  Premature  closure  of  the  fontanelles  does  not 
necessarily  lead  to  idiocy,  backward  development,  or  even  mental  impair- 
ment. 

MIRROR  "WRrnNG. 

An  unusual  and  somewhat  striking  symptom  which  at  times  occurs 
in  severe  and,  as  a  rule,  chronic  cerebral  disease  is  one  which  is  called 
"  mirror  writing,"  which  is  a  condition  represented  by  the  individual 
writing  in  such  a  way  that  the  letters  can  only  be  deciphered  when  they 
are  reflected  in  a  mirror.  This  symptom  is  usually  found  when  there  is 
-cerebral  degeneration  or  among  the  feeble-mmded.  The  actual  pathology 
of  the  affection  has  not  yet  been  determined. 

HYSTERIA. 

Hysteria  is  a  functional  disturbance  of  the  cerebral  centres.  According 
to  the  theory  of  Janet,  it  depends  upon  a  dissociation  of  consciousness 
and  subconsciousness.  Impulses  originate  subconsciously,  which,  lacking 
the  inhibitory  influences  of  the  higher  function  of  consciousness,  lead  to 
most  diverse  mental  and  physical  conditions.  The  name  is  a  misnomer, 
in  that  the  disease  has  no  necessary  connection  with  uterine  disorders, 
but  it  has  been  generally  adopted. 

Etiology. — We  knoAv  very  little  about  the  etiology  of  hysteria.  Well- 
marked  instances  of  the  disease  occur  in  early  life,  usually  in  the  middle 
and  later  periods  of  childhood.  Oppenheim  states  that  he  has  repeatedly 
observed  hysteric  symptoms  in  children  of  from  two  to  three  years  of 
age.     It  is,  however,  a  rare  disease  in  early  childhood,  although  many 


DISEASES    OF   THE   NERVOUS   SYSTEM.  955 

cases  begin  at  puberty.  An  inherited  nervous  organization  or  highly- 
exciting  surroundings,  combined  with  a  lack  of  proper  home  disciphne, 
appear  to  be  the  most  important  factors  in  the  development  of  the  condi- 
tion in  children.  The  direct  exciting  cause  may  be  anything  producing 
mental  or  physical  shock  in  one  who  has  by  inheritance  a  neuropathic 
predisposition.  Events  or  associations  calling  up  from  the  subconscious- 
ness memories  which  have  been  forgotten  by  the  consciousness  may 
precipitate  an  attack  of  hysteria. 

Symptoms.— The  mere  presence  of  emotional  or  imaginative  conditions 
in  children  does  not  constitute  hysteria.  For  the  existence  of  the  disease 
it  is  necessary  to  have  definite  symptoms,  either  a  markedly  disorganized 
mental  state,  paralysis,  aucesthesia,  or  some  serious  loss  of  function. 

The  symptoms  are  innumerable.  Convulsions  and  paralysis  are  com- 
mon, while  dysphagia,  amaurosis,  deafness  and  anaesthesia  are  met  with 
only  in  the  very  severe  cases.  Anaesthesia  is  especially  interestmg  as 
representing  a  pure  type  of  the  disease,  and  is  usuahy  on  one  side  of  the 
body,  hemianaesthesia,  or  it  may  be  of  the  "glove"  or  "stocking"  type 
the  aneesthesia  not  corresponding  to  any  distribution  of  peripheral  nerve 
or  spinal  cord  lesions.  The  anaesthesia  may  extend  to  the  organs  of 
special  sense  leading  to  partial  or  complete  loss  of  function  of  hearing, 
sight,  smell  or  taste,  but  the  last  two  are  hard  to  determine  with  accuracy 
in  early  life. 

Hysteria  in  children  as  usually  seen  in  America  is  marked  by  the 
emotional  conditions  of  the  child,  and  by  the  presence,  in  many  cases,  of 
a  fixed  idea  relating  to  its  own  physical  condition.  The  child  subcon- 
sciously performs  certain  actions  or  functions  which  consciously  he  cannot 
control.  There  probably  has  often  been  in  the  beginning  some  real 
difficulty  or  disturbance  of  the  performance  of  these  functions,  such  as 
pain,  wliich  has  passed  away  or  which  is  not  sufficient  to  produce  the 
present  condition. 

The  most  common  symptoms,  aside  from  the  mental  condition,  are 
convulsions^  paralysis,  ancesthesia  or  hypercesthesia. 

The  convulsions  are  distinguished  from  those  of  epilepsy  by  the 
alteration  rather  than  the  loss  of  consciousness  and  by  the  exaggerated 
character  of  the  movements.  The  patients  may  or  may  not  be  consciously 
aware  of  their  actions  and  surrounchngs,  but  subconsciously,  as  shown  by 
hypnosis,  they  always  know  what  is  taking  place.  In  epilepsy  the  loss 
of  consciousness  is  complete  and  the  memory  of  the  event  cannot  be 
aroused  in  the  subconsciousness.  If  a  patient  is  not  actually  seen  in  an 
attack  the  diagnosis  from  epilepsy  may  be  difficult,  but  the  presence  of 
one  or  more  of  the  stigmata  of  hysteria,  that  is  of  anjesthesia,  hyper- 
gesthesia,  muscular  spasm  or  abulia,  gives  presumptive  evidence  of  the 
hysterical  nature  of  the  convulsion.  The  patient  rarely  seriously  injures 
himself  in  falling,  and  does  not  bite  his  tongue.  He  does  not  sleep  after 
the  attack  but  is  often  dull  and  apathetic. 


956  PEDIATRICS. 

The  paralysis  is  often  of  the  spastic  form,  and  may  be  either  hemi- 
plegic,  paraplegic,  or  monoplegic  if  following  an  injury.  In  this  form  the 
limbs  are  rigid  and  the  knee-jerks  arc  exaggerated.  It  may,  however, 
be  of  the  flaccid  variety,  with  the  knee-jerks  diminished  or  absent.  It  is 
distinguished  from  the  organic  forms  of  paralysis  by  the  normal  reaction 
of  the  muscles  to  electricity,  by  the  absence  of  atrophy,  by  the  absence 
of  any  affection  of  the  sphincters,  and  at  times  by  the  presence  of 
anaesthesia.  When  aneesthesia  occurs  it  is  usually  irregular  in  distribution, 
occurring  in  patches,  or  else  it  suggests  the  distribution  seen  in  cerebral 
organic  disease.  In  organic  disease  the  ansesthesia  generally  grades  off, 
whereas  it  is  sharply  outlined  in  hysteria.  It  is  often  variable,  changing 
more  or  less  from  day  to  day.  Aphonia,  which  was  originally  dependent 
upon  an  acute  laryngitis,  may  persist  for  months  as  an  hysterical  condition 
when  the  organic  cause  has  ceased  to  exist.  In  a  similar  way  inability  to 
walk  because  of  an  acute  rheumatic  fever  affecting  the  knee-joint  may  be 
followed  by  hysterical  paralysis  of  long  duration.  If  a  patient  is  seen  for 
the  first  time  in  the  state  of  hysterical  paralysis  one  may,  by  putting  her 
into  a  condition  of  hypnosis  and  questioning  the  subconsciousness,  learn  the 
association  of  ideas  which  has  given  rise  to  the  paralysis.  By  suggestion 
in  the  hypnotic  state  and  explanations  in  the  conscious  state  the  idea  may 
be  dispelled  and  the  hysterical,  attack  relieved.  The  anaesthesia  so  char- 
acteristic of  hysteria  illustrates  the  dissociation  of  consciousness  and 
subconsciousness.  There  is  no  conscious  sensation  to  touch  or  pain 
during  its  existence,  but  if  the  patient  is  hypnotized  and  questioned  it  may 
be  clearly  demonstrated  that  touch  has  been  perceived  subconsciously. 

We  sometimes  meet  with  an  exaggerated  hysteria  in  children.  The 
attacks  are  represented  by  screaming,  running,  jumping,  and  a  feeling  of 
being  pulled  about ;  they  may  last  for  hours,  or  for  days  i  their  duration, 
however,  is  usually  long, — at  times,  with  intervals,  over  a  year.  No  signs 
of  organic  disease  are  found  in  these  cases ;  they  seldom  injure  them- 
selves, and  are  finally  cured  by  moral  influence,  change  of  scene,  and 
.good  hygienic  surroundings. 

Hysteria  occasionally  causes  children  to  present  symptoms  of  serious 
disease  of  the  spine  and  joints.  This  most  often  follows  some  slight 
injury,  but  may  occur  spontaneously. 

Diagnosis. — The  diagnosis  of  hysteria  is  made  first  by  the  exclusion  of 
organic  disease,  and  then  by  the  presence  of  a  combination  of  symptoms 
which  include  many  diverse  conditions  which  are  not  usually  associated  in 
organic  disease.  The  history  of  a  neuropathic  predisposition  is  of  value 
when  obtained  in  a  case  which  shows  the  symptoms  described.  The 
absence  of  the  reaction  of  degeneration  in  hysteria  enables  us  to  differ- 
entiate hysterical  paralyses  from  those  of  anterior  poliomyelitis.  Generally 
the  diagnosis  is  not  so  difficult  as  in  adult  life,  as  the  child's  mind  is 
less  experienced,  is  less  subject  to  fixed  ideas,  and  is,  therefore,  not  so 
antagonistic  to  suggestion. 


DISEASES    OF  THE   NERVOUS    SYSTEM.  957 

Prognosis.— The  prognosis  in  cases  of  hysteria  in  children  is,  as  a  rule, 
favorable,  but  recurrences  may  take  place  in  later  life. 

Treatment.— Hysterical  children  are  peculiarly  susceptible  to  treat- 
ment by  suggestion,  but  their  management  must  be  placed  in  the  hands  of 
some  one  with  tact  and  firmness,  who  can  appreciate  the  difference 
between  hysterical  symptoms  which  are  not  under  the  control  of  the 
child's  consciousness,  and  similar  conditions,  which  are  often  due  to  bad 
temper  or  malingering.  Regulation  of  the  child's  life  and  environment 
upon  the  principles  of  rational  diet  and  hygiene,  especially  avoiding  excite- 
ment and  over-exertion  of  all  sorts,  Avhether  from  work  or  play,  are  of  the 
first  importance  in  prophylaxis.  The  confidence  of  the  child  must  be 
gained  by  encouragement  and  education.  It  must  be  taught  and  made  to 
overcome  and  control  the  disturbed  functions.  This  is  best  accomplished 
by  those  who  are  especially  experienced  in  mental  therapeutics.  Hypno- 
tism is  justified  only  when  other  methods  fail.  Static  electricity  and 
hydrotherapoutics  are  sometimes  useful  adjuncts  to  the  moral  treatment. 

The  following  case  represents  hysteria  in  a  girl  ten  years  old : 

The  history  of  the  case  was  that  her  parents  were  hving  and  well,  and  that  there  were 
a  number  of  other  healthy  children  in  the  family.  This  child  had  always  been  well 
until  eighteen  days  before  she  entered  the  hospital.  At  that  time  she  complained  of 
headache,  and  on  going  to  school  returned  feeling  sick  and  apparently  unable  to  speak. 
She  was  said  to  have  been  unconscious  at  times,  to  have  had  spasms,  and  to  have  been 
very  restless  at  night.  She  evidently  had  had  great  lack  of  care  in  her  home  life,  and 
had  been  given  only  poor  food.  She  showed  the  evidence  of  this  lack  of  care  in  the 
condition  of  her  skin  and  her  digestion  on  entering  the  hospital.  A  physical  exami- 
nation showed  nothing  abnormal  in  connection  with  the  thorax  and  abdominal  organs. 
The  pupils  were  slightly  dilated,  but  were  equal  and  reacted  to  light.  The  knee-jerks 
were  decreased.  There  was  no  ankle-clonus.  She  was  apparently  unable  to  walk, 
and  she  lay  in  bed  taking  no  notice  of  anything,  but  winked  her  eyes  if  anything  was 
thrust  towards  them.  Her  hearing  did  not  seem  to  be  especially  impaired.  She  lay 
in  a  very  limp  condition,  with  the  legs  drawn  up  in  various  positions.  Her  head 
kept  rolling  from  side  to  side,  and  occasionally  was  retracted.  When  asleep  her  head 
was  retracted  so  as  to  make  nearly  a  right  angle  with  the  body.  It  was  difficult  to  feed 
her,  and  she  would  not  swallow.  Her  temperature  was  37.2°  C.  (99°  F.),  her  pulse 
66,  and  her  respirations  16.     When  being  examined  she  cried  out  a  great  deal. 

She  was  given  plenty  of  good  food,  and  in  three  or  four  days  her  condition  was 
much  improved.  She  took  her  food  well,  but  was  apparently  unable  to  feed  herself. 
A  few  days  later  she  showed  more  intelligence,  and  on  being  taken  up  and  dressed  it 
was  found  that  she  could  sit  alone  and  could  walk  a  little  with  support.  On  beginning 
to  walk  she  threw  her  legs  about  wildly,  but  after  being  scolded  she  walked  much 
better.  At  one  time  when  she  was  sitting  quietly  in  a  chair  the  visiting  physician 
came  into  the  ward,  and  she  immediately  allowed  herself  to  slip  from  the  chair  and 
roll  onto  the  floor,  but  evidently  was  careful  not  to  hurt  herself.  She  at  this  time  cried 
out  a  great  deal,  but  stopped  when  no  notice  was  taken  of  her.  She  was  still  unable 
to  speak,  and,  although  she  could  sit  up  in  a  chair,  apparently  noticed  nothing. 

Nineteen  days  after  entering  the  hospital  she  appeared  much  brighter,  and  began 
to  take  a  slight  notice  of  what  was  going  on  about  her.  When  questioned,  she  moved 
her  lips  as  if  about  to  speak,  but  made  no  sound.  She  continued  to  improve  slowly, 
and  a  few  days  later  said  "sister,"  understood  what  she  was  told  to  do,  and  attempted 


958  PEDIATRICS. 

to  do  it.  She  also  walked  three  steps  without  being  assisted.  Some  days  later  it  was 
found  that  she  would  repeat  almost  any  word  that  was  said  to  her,  but  in  a  whisper. 
After  this  she  improved  rapidly  and  began  to  articulate  fairly  well,  but  slowly  and  with 
an  effort.  She  also  spoke  voluntarily  two  or  three  times.  She  could  not  walk  without 
assistance,  as  she  would  put  her  foot  too  far  forward.  She  had  been  very  much  con- 
stipated through  the  whole  attack,  but  at  this  time  the  constipation  grew  less.  A  defi- 
nite training  of  the  arms  and  legs  was  then  begun  by  means  of  passive  movements  and 
massage.  Under  this  treatment  she  greatly  improved,  and  on  the  thirty-fifth  day  from 
the  time  when  she  entered  the  hospital,  recovered  completely. 

CATALEPSY. 

Catalepsy  is  a  form  of  hysteria  and  may  occur  idopathically  or  be  pro- 
duced by  hypnosis.  It  denotes  a  condition,  apparently  of  cerebral  origin, 
in  which,  together  with  total  or  partial  loss  of  consciousness,  the  limbs 
assume  a  peculiar  form  of  rigidity  called  waxy,  and  remain  for  a  consid- 
erable time  in  any  position  in  which  they  may  be  placed.  It  occurs  at  all 
ages,  but  is  very  rare  in  childhood.  The  youngest  case  that  we  know  of 
is  that  of  a  little  girl  three  years  old,  reported  by  A.  Jacobi. 

The  prognosis  and  treatment  are  those  of  the  primary  disease.  The 
cases  are  treated  as  in  hysteria.  The  immediate  attack  may  often  be 
cured  by  producing  vomiting  by  means  of  apomorphine  given  sub- 
cutaneously. 

SIMULATED  DISEASES. 

On  the  boundary-line  between  children  who  evidently  are  suffering 
from  the  need  of  judicious  disciphne  and  those  who  may  be  said  to  have 
the  definite  disease  hysteria,  is  a  class  of  cases  in  which  simulation  appears 
to  play  an  etiological  part.  These  children  are  usually  in  the  later  period 
of  childhood,  and  seem  to  have  such  perverted  functions  of  their  nervous 
centres  as  actually  to  represent  pictures  of  diseases  which  are  easily  proved 
not  to  be  present.  A  great  variety  of  symptoms  may  be  imitated.  Some 
of  the  patients  are  obviously  malingerers,  but  in  others  the  condition  is 
closely  allied  to  hysteria. 

The  best  treatment  for  these  cases  is  to  put  the  child  to  bed  and  to 
deprive  it  of  its  usual  pleasures  and  amusements.  Rigid  discipline  and 
moral  suasion  must  supplement  this  method  of  punishment. 

INSOLATION. 

Heat-insolation,  or  heat-stroke,  is  a  condition  apparently  represented 
by  a  functional  disturbance  connected  with  the  cerebral  circulation  and 
produced  by  heat.  This  affection  in  varying  degrees  is  of  somewhat  fre- 
quent occurrence  in  children,  and  is  supposed  to  be  accompanied  by  a 
hyperasmiaof  the  meningeal  blood-vessels  of  greater  or  less  intensity,  with 
general  venous  congestion  throughout  the  body.  It  is  met  with  most  com- 
monly in  the  middle  period  of  childhood,  because  at  that  age  the  child  is 
most  likely  to  be  exposed  to  the  influences  which  produce  it. 

Symptoms. — The  clinical  picture  of  this  class  of  cases  is,  as  a  rule,  quite 
characteristic.     The  child  has  perhaps  been  playing  on  a  hot  summer's 


DISEASES   OF   THE   NERVOUS   SYSTEM.  959 

day  somewhat  more  vigorously  than  usual,  possibly  romping  with  an  older 
child  of  more  highly  developed  ner^^ous  resistance,  getting  intensely  ex- 
cited, and  greatly  overtaxing  its  muscular  strength.  It  may  be  that  it  has 
been  exposed  to  the  direct  rays  of  the  mid-day  sun,  or  it  may  have  been 
playing  in  some  covered  but  heated  and  stifling  place.  The  child's  nurse, 
noticing  the  extremely  flushed  condition  of  its  face  and  head  and  its 
excited,  sparkling  eyes,  takes  alarm  and  hurries  it  to  its  home.  Intense 
headache  soon  comes  on,  and  m  a  few  hours  delirium  may  supervene. 
The  sldn  is  hot,  dr>-,  and  reddened ;  there  may  be  vomiting  in  the  begin- 
ning ;  the  carotids  and  temporal  arteries  throb  perceptibly.  The  heart's 
action  is  violent,  and  the  temperature  is  raised  to  38.9°-39.4°-40°  C. 
(102°-103°-104°  F.);  the  pulse  is  much  accelerated,  perhaps  140  to 
150,  and  is  full,  but  usually  rhythmical.  The  conjunctivge  are  congested 
and  the  pupils  contracted.  Photophobia  to  a  greater  or  less  degree  is 
almost  invariably  present.  Beyond  this  there  may  be  no  symptoms  ex- 
cept a  slight  amount  of  muscular  twitching,  and  in  some  cases  a  convul- 
sion may  occur  if  the  temperature  runs  as  high  as  40°  to  40.6°  C.  (104°  to 
105°  F.).  The  temperature,  however,  in  accordance  with  the  rule  in  tliis 
disease  as  in  others  which  occur  in  children,  does  not  always  produce  the 
same  or  ec|ually  severe  symptoms.  Convulsions  may  occur  as  a  very 
connnon  form  of  nerv' ous  explosion  when  fever  and  disturbance  of  the 
cerebral  circulation  are  present,  but,  as  a  rule,  this  symptom  is  absent. 

Prognosis. — ^We  should  be  careful  as  to  the  prognosis  given  m  these 
cases.  Although  they  often  simulate  closely  a  beginning  meningitis,  yet 
they  are  xerj  amenable  to  treatment,  and  should  therefore  be  carefully 
differentiated  from  that  disease.  In  Yerj  severe  cases  the  children  may,  of 
course,  die  of  insolation. 

Diagnosis. — The  diagnosis  from  meningitis  is  based  upon  the  hist  on", 
the  milder  grade  of  the  symptoms,  except  the  headache,  and  finally,  in 
doubtful  cases,  on  the  rapid  recovery  and  speedy  disappearance  of  the 
fever. 

Treatment. — The  treatment  of  heat-insolation  with  severe  symptoms 
and  high  temperatures  should  be  prompt  and  vigorous.  A  stimulating 
enema  of  salt,*one  teaspoonful  to  a  c|uart  of  cold  water,  should  first  be 
given.  The  child  should  then  be  placed  upon  a  bed  protected  by  a  rubber 
sheet  in  a  cool,  darkened  room  ;  a  warm  mustard  pack  should  be  applied 
to  the  lower  extremities,  and  the  neck  and  chest  gently  sponged  with 
water  at  25°  C.  (77°  F.)  for  fifteen  minutes  out  of  ever)'  hour.  Letter's 
coil  should  be  apphed  to  the  head  with  water  at  5°  C.  (41°  F.);  bromide 
of  potassium  should  be  given,  0.3  gramme  (5  grains)  every  hour  for  four 
doses ;  a  little  iced  milk  may  be  taken  if  the  child  cares  for  it,  not  more 
than  one  or  two  ounces  at  a  time  ;  and  complete  rest  and  quiet  for  at 
least  twenty-four  hours  are  usually  indicated.  Stimulants  by  mouth  and 
subcutaneous  injection  should  be  given  when  needed.  The  child  should 
be  watched  carefully  for  some  days  and  not   allowed  to   play  actively 


960  PEDIATRICS. 

enough  to  get  heated.  Great  care  should  be  taken  for  the  rest  of  the 
summer  to  protect  the  child  from  the  direct  rays  of  the  sun,  as  after  one 
attack  the  cerebral  circulation  remains  in  a  very  sensitive  condition  for  a 
considerable  period. 

Mild  cases  occur  which  do  not  call  for  such  vigorous  treatment.  Rest 
in  bed,  small  doses  of  brandy  or  aromatic  spirits  of  ammonia,  and  a  light 
diet  of  milk  and  lime-water  are  all  that  is  required  in  these  cases. 

CONCUSSION. 

By  concussion  we  mean  clinically  a  group  of  symptoms  following 
some  physical  shock,  with  its  resulting  traumatic  irritation  of  the  nervous 
centres.  It  varies  in  character  and  duration  according  to  the  severity  of 
the  lesions.  There  may  be  only  a  brief  alteration  in  the  cerebral  circula- 
tions giving  rise  to  very  transitory  symptoms,  or  more  serious  lesions, 
such  as  cerebral  oedema,  minute  hemorrhages,  and  lacerations  of  brain 
tissue.  The  chief  symptoms  are  an  alteration  or  loss  of  consciousness, 
headache,  and  sometimes  vomiting  and  rapid  pulse,  which  becomes  slow 
if  oedema  or  hemorrhage  develops.  There  may  also  be  amnesia  and 
aphasia.  Recovery  takes  place  rapidly  or  slowly,  depending  upon  the 
nature  of  the  trouble.     Epilepsy  may  develop  later  in  the  severer  forms. 

The  treatment  of  a  case  of  this  kind  is  simply  by  perfect  rest  and 
quiet  in  a  darkened  room,  with  hot  applications  to  the  feet  and  abdomen, 
and  small  and  repeated  doses  of  stimulants  given  by  enemata  until  the 
stomach  is  able  to  retain  them,  the  treatment  being  continued  until  the 
circulation  is  normal  and  the  pulse  strong. 

TEMPORARY  AMNESIA. 
The  following  case  of  temporary  amnesia  represents  a  class  of  nervous 
disturbance  the  pathology  of  which  we  know  nothing  of  and  the  causes 
of  which  are  manifold  : 

A  boy,  thirteen  years  old,  while  running  struck  his  head  against  a  tree.  I  saw 
him  three  hours  later.  He  had  walked  home,  but  was  a  little  nauseated,  and  was  put 
to  bed.  We  found  that  he  had  partial  loss  of  memory  and  was  drowsy,  but  that  he  had 
no  especial  pain.     He  was  perfectly  well  on  the  following  day. 

TEMPORARY  APHASIA. 
An  instance  of  suspension  of  the  cerebral  function  connected  with  the 
elaboration  of  words  is  illustrated  by  Demme's  case, 

A  child,  six  years  old,  previously  well  and  bright,  suddenly  lost  the  power  of 
speech.  This  phenomenon  occurred  during  an  operation  for  talipes,  which  was  being 
performed  without  an  anaesthetic.  After  the  operation  the  child  was  perfectly  well, 
but  was  unable  to  elaborate  words  until  the  ninth  day,  when  she  began  to  use  the  one 
word  ' '  mamma' '  for  everything  she  wanted  to  say.  She  then  gradually  increased 
her  vocabulary  until  the  twenty-first  day,  when  her  aphasia  disappeared  entirely  and 
she  developed  mentally  and  physically  in  a  normal  manner. 


DISEASES   OF  THE   NERVOUS   SYSTEM.  961 

HEADACHES. 

When  pain  in  the  head  occurs  in  early  Kfe  it  is  to  be  regarded  more 
seriously  than  at  a  later  period,  as  it  is  more  apt  to  indicate  some  grave 
central  lesion.  The  various  forms  of  organic  headache  which  arise  in 
children  can  be  spoken  of  best  as  symptomatic  of  the  various  diseases  in 
which  they  occur,  such  as  typhoid  fever,  and  tumors  of  the  brain. 

There  also  appears  to  be  a  type  of  headache  Avhich  occurs  in  the  later 
years  of  childhood  irrespective  of  any  definite  disease  and  is  often  unac- 
companied by  nausea.  These  headaches,  as  a  rule,  are  not  of  serious 
import,  and  are  usually  classed  under  the  term  functional.  They  occur 
irregularly,  and  may  be  in  any  part  of  the  head.  They  are  often  so 
severe  that  the  child  has  to  lie  down.  The  intervals  between  the  attacks 
are  variable,  and  the  length  of  the  attacks  varies  from  two  to  three  hours 
to  a  day.  Of  these  functional  headaches  the  most  frequent  form  in  chil- 
dren is  that  due  to  antemia.  It  is  always,  however,  wiser  to  look  upon 
this  form  of  headache  as  a  symptom  of  some  undetermined  disease. 

Although  in  many  cases  headaches  are  caused  by  an  improper  regula- 
tion of  the  diet,  yet  there  is  evidently  some  other  cause  which  we  do  not 
recognize  in  their  production,  as  with  exactly  the  same  diet  for  many 
months  a  child  will  show  no  symptoms  whatever  of  headache.  In  hke 
manner,  although  we  knoAv  that  headaches  in  children  may  depend  upon 
constipation,  yet  this  class  of  cases  occurs  whetner  constipation  is  present 
or  not.  The  source  of  the  headache  cannot  be  determined  by  the  part 
of  the  head  affected. 

Migraine  also  may  exist  in  children,  and  is  characterized  by  severe 
pain  in  the  head,  sometimes  unilateral,  sometimes  bilateral,  accompanied 
by  nausea,  dizziness,  and  generally  vomiting.  The  attacks  occur  at 
irregular  intervals,  and  usually  last  the  greater  part  of  a  day.  They  may 
be  brought  on  by  apparently  slight  causes,  such  as  over-fatigue,  eye-strain, 
or  very  mild  indiscretions  of  diet,  in  those  predisposed  to  them.  These 
headaches  are  markedly  hereditary.  Migraine  may  appear  in  later  life  in 
cases  which  in  childhood  have  been  subject  to  persistent  or  periodic 
vomiting. 

Although  all  these  forms  of  headache  are  ordinarily  very  intractable  to 
cure,  especially  when  no  bad  hygienic  surroundings  exist  which  might 
account  for  them,  and  when  the  child  does  not  lead  a  sedentary  life,  yet, 
as  a  rule,  the  attacks  have  a  tendency  to  lessen  and  disappear  as  the  child 
grows  older. 

Treatment. — One  of  the  most  common  causes  in  children  is  pain  caused 
by  strain  of  the  eyes.  In  all  cases  of  headache  in  children  the  cause  of 
which  is  not  evident,  a  careful  examination  of  the  eyes  should  be  made, 
even  though  there  be  no  symptoms  which  point  to  the  eyes  themselves. 
The  treatment  of  headache  should  be  directed  to  that  of  the  disease  which 
is  causing  the  disturbance  when  it  can  be  detected,  as  in  antemia  or 
hypereemia    from  various  causes,   gastric  disturbances,     the    prodromal 

61 


962  PEDIATRICS. 

stages  of  the  acute  infectious  diseases,  malaria,  uraemia,  and  otlier  toxic 
causes ;  when,  however,  no  cause  can  be  found,  a  darkened  room  and 
sufficient  bromide  of  soda  to  allay  pain  and  produce  sleep  are  indicated. 
Antipyrin,  phenacetin,  ammonol,  kryofnie,  and  many  other  analgesics 
may  be  employed  temporarily  to  relieve  the  headache  while  the  cause  is 
being  sought  and  treated. 

VERTIGO. 

Vertigo  at  times  occurs  in  children.  It  is  a  term  applied  to  a  condi- 
tion in  which  the  individual  or  the  objects  around  him  appear  to  be  rolling 
about.  It  is  called  subjective  vertigo  when  the  patient  himself  seems  to 
be  turning,  and  objective  vertigo  when  it  is  the  surrounding  objects  that 
appear  to  move. 

Vertigo  has  a  variety  of  causes.  It  may  be  due  to  organic  cerebral 
diseases,  such  as  tumors  of  the  brain,  especially  of  the  cerebellum,  and  to 
diseases  of  the  ear  and  of  the  eye.  It  may  also  be  due  to  circulatory 
disturbances,  as  in  cardiac  disease,  and  to  the  stomach,  as  from  improper 
food,  from  tobacco  and  tea  and  as  a  result  of  anaemia. 

The  following  case  illustrates  this  condition  : 

A  boy,  thirteen  years  old,  had  had  a  purulent  otitis  for  several  years,  but  this  had 
healed  three  years  previously,  leaving  a  condition  of  adhesions  and  cicatrices  with  con- 
siderable imijairment  of  hearing,  but  with  no  trouble  of  the  labyrinth  nor  any  symp- 
toms pointing  to  if. 

He  was  always  strong  and  well  until  he  was  seven  years  old.  At  ten  years  he 
began  to  have  attacks  of  dizziness  accompanied  by  seeing  white  spots.  At  times  he 
had  nausea.  A  sensation  of  spinning  around  or  falling  subsequently  developed,  was 
constant,  and  increased  in  severity.  He  had  no  other  abnormal  symptoms  except 
weakness.  He  slept  well,  his  appetite  was  fair,  and  his  bowels  were  regular.  He  had 
good  hygienic  surroundings,  did  not  smoke,  and  had  never  lived  in  a  malarial  district. 
He  was  a  close  student  and  led  a  sedentary  life.  He  had  never  had  any  headache.  He 
drank  much  tea.  He  was  directed  to  stop  drinking  tea  and  to  ride  on  horseback. 
Within  a  few  weeks  after  the  active  exercise  had  been  begun  and  the  tea  had  been 
omitted  from  his  diet,  the  boy  ceased  to  have  attacks  of  vertigo. 

PAVOR  NOOTURNUS. 

The  night-terrors  of  children  may  occur  from  a  variety  of  causes,  and 
should  not  be  considered  as  one  disease,  but  as  a  symptom  of  a  number 
of  diseases.  Any  nervous  disturbance,  whether  central  or  peripheral, 
may  produce  so  profound  an  impression  on  the  sensitive  cortical  cells  of 
the  brain  that  the  child's  sleep  may  be  disturbed  by  a  cortical  irritation. 
Hearty  meals  at  night,  excitement  and  fatigue  from  excessive  work  or  play 
and  especially  harrowing  tales  are  common  causes.  They  are  generally 
symptomatic  of  a  neuropathic  predisposition,  and  the  lives  of  children 
who  are  subject  to  them  should  be  regulated  with  particular  care. 

The  following  case  represents  the  special  form  of  pavor  nocturnus 
which  may  be  considered  central: 


DISEASES   OF   THE   NERVOUS   SYSTEM.  963 

A  boy,  six  years  of  age,  had  always  been  a  delicate,  thin,  pale  child,  not  caring 
much  for  out-of-door  exercise,  but  inclined  to  remain  in  the  house  and  to  be  read  to  or 
to  have  exciting  stories  told  to  him.  His  appetite  was  poor.  He  was  mentally  bright 
and  precocious.  Otherwise  he  appeared  to  be  well,  and  showed  no  signs  of  any  organic 
disease.  One  evening  he  was  allowed  to  sit  up  rather  later  than  usual,  and  a  number 
of  terrifying  stories  were  told  to  him.  He  went  to  sleep  as  usual,  but  in  about  an 
hour  waked  up  screaming.  He  was  found  sitting  up  in  bed  looking  terrified.  His  eyes 
were  staring  at  some  invisible  object,  evidently  a  picture  in  his  brain  and  not  a  reality  ; 
he  was  pointing  at  this  imaginary  source  of  his  terror,  and  kept  repeating  that  it  was  a 
black  dog.  It  was  impossible  to  pacify  him  for  about  ten  minutes,  and  he  did  not 
recognize  his  mother  during  the  attack.  He  then  became  more  quiet ;  the  wild  look 
passed  from  his  eyes  ;  he  recognized  his  mother,  and  soon  lay  down  and  went  quietly 
to  sleep.  The  cause  of  this  attack,  Avhich  is  typical  of  the  central  form  of  pavor  noc- 
turnus,  was  evidently  an  undue  excitement  of  the  cells  of  the  cortex  in  a  bright,  nervous 
child  before  going  to  sleep.  The  treatment  of  a  case  of  this  kind  is  to  accustom  the 
child  to  more  exercise  in  the  open  air,  to  prevent  his  reading  anything  but  the  most 
ordinary  and  simple  books,  and  to  have  no  stories  whatever  related  to  him,  especially 
at  night. 

The  following  case  represents  the  peripheral  form  of  pavor  nocturnus  : 

A  girl,  three  years  old,  had  been  always  well  and  strong  ;  she  had  a  good  appetite  ; 
was  not  nervous  or  excitable  ;  she  was  fond  of  playing  out  of  doors,  and  was  not  fond 
of  having  stories  told  to  her.  She  was  constipated,  and  had  a  tendency  to  overload  her 
stomach.  She  had  eaten  a  very  heavy  supper,  and  on  going  to  bed  immediately  fell 
asleep,  but  soon  began  to  be  restless,  to  throw  herself  about,  to  groan,  and  to  grind 
her  teeth.  A  little  later  she  woke  up  screaming,  and  apparently  had  a  certain  amount 
of  dyspnoea.  She  did  not  recognize  her  mother,  but  sat  up  in  bed  looking  very  much 
frightened  and  clutching  at  her  throat.  Her  mother  made  her  drink  some  warm  water, 
which  produced  copious  vomiting.  She  then  became  rational  again,  recognized  her 
mother,  and  soon  lay  down  and  went  to  sleep.  She  had  no  recollection  of  the  attack  on 
the  following  day. 

The  irritation  in  this  case  was  of  the  terminal  filaments  of  the  pneumogastric 
nerve  in  the  stomach,  causing  reflex  symptoms  of  the  nervous  centres  to  such  an  extent 
that  the  child  was  terrified  and  felt  as  though  she  would  stifle. 

The  treatment  in  cases  of  this  kind  should  be  by  moderating  the  diet  and  allow- 
ing the  child  to  have  only  a  light  and  digestible  supper.  The  two  classes  of  cases  are 
distinct  and  their  treatment  is  entirely  different.  A  mixture  of  both  of  these  forms  is 
frequently  met  with,  between  which  it  is  not  possible  to  make  a  clear  distinction. 

TREMOR. 

Universal  or  partial  tremor  is  rare  in  infancy  and  in  early  childhood  in 
comparison  with  later  life.  It  does,  however,  occur,  and  is  usually  signifi- 
cant of  an  organic  cerebral  lesion.  We  have  noticed  it  also  in  cases  of 
infantile  atrophy,  in  which  as  recovery  gradually  took  place  the  tremor 
disappeared.  In  this  form  it  appears  to  be  chiefly  a  symptom  of  weak- 
ness. It  may  be  quite  marked  as  a  general  symptom,  but  it  is  not  espe- 
cially significant,  either  in  respect  to  the  diagnosis  or  to  the  prognosis. 
Tremors  also  occur  in  children  in  the  acute  infectious  diseases,  such  as 
typhoid  fever  and  pneumonia,  in  meningitis,  exophthalmic  goitre,  multiple 
sclerosis,  and  Friedreich's  disease. 


964  PEDIATRICS. 

TETANY. 
With  the  knowledge  which  we  have  at  present  of  this  condition  we 
must  look  upon  tetany  as  a  symptom  of  nervous  irritation  and  not  a  defi- 
nite disease.  The  condition  is  represented  by  tonic  intermittent  paroxysmal 
muscular  contractures  varying  in  duration  and  intensity.  Although  the 
seat  of  these  contractures  may  be  in  other  parts,  such  as  the  neck,  face, 
and  thorax,  yet  the  chief  and  characteristic  parts  are  the  hands  and  arms, 
legs  and  feet.  The  wrist  is  sharply  flexed  and  turned  outward  ;  the  thumb 
in  the  position  of  extension  is  drawn  across  the  palm  of  the  hand  beneath 
the  fingers,  which  are  flexed  at  the  metacarpo-phalangeal  joints,  but  other- 
wise are  in  the  position  of  extension.  The  feet  are  rigidly  extended  and 
may  be  in  the  position  of  talipes  equinus  or  of  equino-varus.  The  pha- 
langes of  the  toes  are  flexed  and  extended  in  the  same  way  as  those  of 
the  fingers.  Tetany  as  a  term  should  be  used  only  when  these  character- 
istic contractures  are  present,  and  should  not  be  applied  to  other  condi- 
tions of  increased  reflex  excitability.  Moderate  opisthotonos  may  occur. 
The  knee-  and  hip-joints  are  usually  not  affected. 

Fig.  193. 


Showing  the  characteristic  spasm  of  tetany  in  an  infant  of  6  months,  who  was  breast  fed  and  showed 
only  slight  degrees  of  malnutrition  and  rhachitis. 

Etiology. — Tetany  is  a  symptom  of  a  number  of  different  conditions, 
and  is  not  pathognomonic  of  any  one  disease.  It  is  at  present  believed 
that  certain  toxins  may  be  developed  which  affect  the  central  or  periph- 
eral nervous  system.  This  is  especially  liable  to  occur  in  gastro-enteric 
diseases,  in  rhachitis,  in  various  acute  diseases,  such  as  pneumonia,  and 
especially  where  the  hygienic  surroundings  are  bad.  Dilatation  of  the 
stomach  is  a  common  cause  of  tetany. 

Pathological  Anatomy. — There  is  no  definite  morbid  condition  with 
which  tetany  is  associated.  The  condition  is  functional  rather  than 
organic,  and,  according  to  Osier,  certain  forms  depend  on  the  loss  of  the 
function  of  the  thyroid  gland. 

Symptoms. — The  pecuhar  spasmodic  conditions  described  above  vary  in 
their  duration,  and  are  usually  paroxysmal.  They  may  last  only  a  few 
minutes  or  for  hours  or  even  days.  Pain  is  at  times  present,  especially 
when  the  attempt  is  made  to  overcome  the  spasm.  The  temperature  and 
pulse^  according  to  the  exciting  disease,  are  increased.     The  electrical  ex- 


DISEASES   OF   THE   NERVOUS   SYSTEM.  965 

citability,  mechanical  excitability,  cutaneous  reflexes,  and  knee-jerks  are 
increased. 

Trousseaus  symptom  (compression  of  the  large  nerve-trunks  or  blood- 
vessels of  the  parts  affected  bringing  on  the  paroxysms)  is  generally  present, 
and  in  some  cases  Chvosiek's  symptom  (active  contraction  of  the  muscles 
supplied  by  the  facial  nerve  produced  by  a  slight  tap  on  the  course  of  the 
nerve)  can  be  obtained.  Laryngospasmus  occurs  in  certain  cases,  espe- 
cially when  rhachitis  is  present.  When  the  muscles  of  the  trunk  are 
involved,  dyspnoea,  cyanosis,  and  even  opisthotonos  may  occur. 

Diagnosis. — The  peculiar  bilateral  spasms  usually  occurring  in  the 
course  of  such  diseases  as  rhachitis  or  gastro-enteric  disturbance,  espe- 
cially when  combined  with  Trousseau's  and  Chvostek's  symptoms,  serve 
to  distinguish  true  tetany  from  other  nervous  manifestations  of  muscular 
irritability.  From  tetanus  the  diagnosis  is  made  by  the  absence  of  trismus, 
the  presence  of  Trousseau's  and  Chvostek's  signs  and  the  characteristic 
position  of  the  hands  and  feet ;  from  meningitis  by  the  absence  of  head- 
ache, fever,  loss  of  consciousness,  retraction  of  the  head,  rigidity  of  the 
neck  and  by  the.  character  of  the  spasms  ;  and  from  cerebral  tumor  by  the 
absence  of  headache,  optic  neuritis  and  other  symptoms  of  pressure. 

Prognosis. — The  symptom  in  itself  is  not  a  serious  one,  the  danger  de- 
pending upon  the  gravity  of  the  special  disease  which  is  causing  the  tetany. 

Treatment. — The  general  nutrition  of  the  child  should  receive  careful 
attention.  Hot  baths,  chloral,  and  bromides,  are  indicated.  The  en- 
deavor should  be  made  to  remove  the  especial  cause,  which  is  frequently 
to  be  found  in  the  gastro-enteric  tract.  The  bowels  should  be  moved 
freely  by  laxatives.  Thyroid  extract  should  be  tried  when  no  primary 
cause  for  the  tetany  can  be  determined  and  other  treatment  is  found  to  be 
inefficacious. 

DENTAL  REFLEXES. 

The  twitching  which  occurs  in  children  at  the  time  when  a  tooth  is  the 
apparent  cause  of  a  certain  amount  of  discomfort  and  fever  should  be 
referred  to  here  as  a  significant  illustration  of  nervous  phenomena  from 
reflex  causes.  The  cases  are  numerous,  but  scarcely  of  sufficient  impor- 
tance to  report.  In  certain  instances,  however,  convulsions  of  a  reflex 
nature  occur  at  this  time  and  cease  when  the  tooth  has  assumed  its  place 
above  the  margin  of  the  gum.  We  have  also  met  with  some  interesting 
cases  of  local  oedema  arising  during  the  period  of  dental  irritation,  and 
usually  spoken  of  as  angio-neurotic  oedema. 

One  of  these  cases  was  a  male  infant,  fifteen  months  old,  who  some  months  pre- 
viously, while  cutting  one  of  the  second  molars,  had  an  attack  of  oedema  of  the  hands, 
which  was  not  accompanied  by  irritation  or  any  other  symptom,  and  which  passed  off 
after  a  few  hours. 

This  same  boy  when  the  canine  teeth  were  about  to  come  tlirough  the  gums  was 
asain  attacked  by  oedema  of  the  face.  This  local  oedema,  as  in  the  previous  instance, 
disappeared  quickly. 


966  PEDIATRICS. 

At  times  we  have  seen  a  local  oedema  attacking  one  eyelid,  so  that  the 
eye  could  not  be  opened. 

Although  we  cannot  say  that  irritation  from  the  teeth  is  necessarily 
the  cause  of  these  conditions,  yet  they  so  often  arise  during  the  dental 
period,  and  not  during  other  periods  of  childhood,  or  before  the  fourth  or 
fifth  month,  that  Ave  can  at  least  say  that  in  individuals  of  an  excessively 
nervous  temperament  the  irritation  which  evidently  arises  in  certain  cases 
when  the  teeth  are  developing  may  be  sufficient  to  cause  a  nervous  explo- 
sion, which  in  this  sense  may  be  spoken  of  as  of  dental  origin. 

NYSTAGMUS. 
By  nystagmus  is  meant  a  peculiar  rhythmical  oscillation  of  the  eye- 
balls, usually  from  side  to  side,  but  in  some  cases  up  and  down.  It  occurs 
occasionally  as  a  congenital  disease  and  may  persist  throughout  life.  It 
may  sometimes  be  dependent  on  organic  disease  of  the  brain,  such  as 
multiple  sclerosis,  cerebellar  tumor  or  abscess,  hydrocephalus  and  men- 
ingitis, and  again  may  arise  from  local  diseases  of  the  eye,  so  that  a  careful 
examination  of  the  central  nervous  system  and  an  expert  examination  of 
the  eyes  should  always  be  made.  In  many  cases,  however,  this  condition 
appears  to  be  purely  reflex  from  various  peripheral  stimuli,  and  is  not  a 
very  uncommon  symptom  in  young  children.  We  have  notes  of  two 
cases,  brothers,  who  during  the  dental  period  showed  this  oscillation  of 
the  eyeballs  with  no  other  symptoms.  Complete  recovery  resulted  when 
dentition  was  complete.  The  cause,  however,  of  the  reflex  irritation  must 
always  be  looked  for,  and  it  must  not  be  taken  for  granted  that  the  chief 
etiological  factor  is  dentition,  for  in  many  cases  disturbance  of  the  gastro- 
enteric tract  is  present. 

GYROSPASM  AND  SPASMUS  NUTANS. 
Gyrospasm  (rotary  movements  of  the  head)  and  spasmus  nutans 
(nodding)  are  peculiar  movements  of  the  head  in  young  children  which 
are  apparently  of  reflex  origin,  and  are  at  times  associated  with  nystag- 
mus and  strabismus.  The  chief  causes  are  idiocy,  rhachitis,  gastro-enteric 
irritation,  and  dentition.  The  prognosis  is  usually  good  except  in  idiocy. 
The  best  treatment  is  with  the  bromides. 

REFLEX   SYMPTOMS  OF  THE  EAR. 
The  reflex  connection  between  the  roots  of  the  teeth  and  the  mem- 
brana  tympani  by  means  of  the  otic  ganglion  produces  the  well-known 
reflex  earache  which  occurs  during  the  dental  period.     This   has  been 
described  on  page  634. 

REFLEX   SYMPTOMS  OP  THE  LARYNX. 

In   certain   cases   reflex   symptoms   occur  in  the  larynx.     They   are 

usually  noted  during  infancy  rather  than  in  childhood.     The  affection  has 

been  called  laryngospasmus,  and  although  it  is  more  usual  for  it  to  occur 

in  rhachitic   chfldren  than  in  others,   it  is  not  necessarily  confined  to 


DISEASES   OF   THE   NERVOUS   SYSTEM.  967 

rnachitis.     It  is  not  in  our  experience  a  very  common  disease,  but  when 
met  with  it  is  very  characteristic. 

Symptoms.— The  infant  is  suddenly  attacked  by  an  inspiratory  or  ex- 
piratory spasm  of  the  larynx.  This  condition  may  be  precipitated  by 
various  causes,  such  as  fright  and  excitement.  We  have  also  seen  it  produced 
by  various  peripheral  irritations,  such  as  those  of  the  nose.  At  times  the 
attack  is  so  severe  that  the  infant  becomes  unconscious  and  cyanotic.  The 
attack  lasts  for  only  a  few  minutes,  and  on  recovery  the  infant  seems  as 
well  as  ever.  There  does  not  seem  to  be  an  inflammatory  condition  con- 
nected with  this  symptom,  and  apparently  it  is  purely  of  a  reflex  nature. 
In  some  cases  a  crowing  laryhgeal  sound  will  frequently  precede  and  often 
succeed  the  more  severe  stage  of  the  attack. 

Prognosis. — The  prognosis  in  cases  of  laryngospasmus  is,  as  a  rule, 
favorable,  although  very  weak  infants  may  die  in  an  attack. 

Treatment. — As  the  infants  are  usually  dehcate  and  of  a  highly  ner- 
vous organization,  the  treatment  should  be  directed  to  improvement  of 
their  general  health  and  to  protection  from  nervous  excitement  until  they 
have  attained  an  age  when  their  nervous  system  is  less  irritable  and  is  in 
more  stable  equilibrium.  During  an  attack  the  treatment  is  to  endeavor 
to  produce  relaxation  of  the  spasm  by  peripheral  irritation  elsewhere. 
This  is  usually  done  by  showering  the  child  on  the  chest  and  face  with 
cold  water  and  lightly  slapping  the  back. 

Among  a  number  of  cases  of  this  kind  which  have  come  under  our 
notice  was  this  one  : 

A  boy,  one  year  old,  had  always  shown  a  nervous  temperament  and  had  had  a 
number  of  convulsions  when  he  was  cutting  his  first  teeth.  With  the  exception  of  a 
light  attack  of  epidemic  influenza,  he  had  been  well  and  strong.  Following  the  attack 
of  epidemic  influenza,  in  which  the  nasal  symptoms  were  prominent,  he  was  left  with 
a  very  irritable  naso-pharynx.  He  then  began  to  have  attacks  characterized  as 
follows  : 

Whenever  the  nurse,  while  giving  him  a  bath,  attempted  to  cleanse  his  nose,  no 
matter  how  gently,  he  would  immediately  gasp,  with  a  catching  sound  in  his  breath- 
ing, become  rigid,  draw  himself  back  sometimes  almost  to  the  position  of  opisthotonos, 
become  unconscious  and  cyanotic,  and  then  after  a  few  seconds  the  spasm  would  pass 
away  and  he  would  seem  perfectly  well  again.  These  attacks  continued  for  some 
months  without  apparently  harming  him,  and  they  then  grew  less  frequent  and  passed 
away  entirely. 

As  additional  examples  of  reflex  phenomena  of  the  larynx  having 
their  origin  in  the  ear  may  be  mentioned  the  hoarseness  which  sometimes 
accompanies  the  impaction  of  cerumen  in  the  ears,  and  which  disappears 
almost  immediately  after  the  removal  of  the  mass.  Blake  reports  a  case 
in  which  a  persistent  laryngeal  cough  of  several  months'  duration  was 
immediately  relieved  by  the  removal  of  a  bead  from  the  external  auditory 
canal.  These  cases,  as  well  as  those  in  which  there  is  a  "eflex  cough, 
can  be  explained  by  means  of  the  following  diagram,  whicli  shows  the 
reflex  connection  between  the  ear  and  the  larynx. 


968 


PEDIATRICS. 


The  irritation  of  the  sensitive  fibres  of  the  auriculo-pneumogastricus 
distributed  in  the  meatus  and  in  the  membrana  tympani  is  reflected 
along  the  motor  fibres  of  the  superior  laryngeal  nerve,  exciting  in  the 
larynx  the  act  of  coughing  by  causing  contraction  of  the  crico-thyroid 
muscle.  When  the  original  irritant,  either  in  the  meatus  or  in  the  mem- 
brana tympani,  by  its  continued  presence  involves  the  vaso-motor  fibres 
associated  with  the  auricular  nen-e,  they  conduct  their  impression  to  the 
ganghon  of  the  pneumogastric,  and  thence  it  is  deflected  through  a  sympa- 
thetic fasciculus  proceeding  from  it  to  the  first  cervical  ganglion.     This 


Reflex  connection  between  the  ear  and  the  larynx.  A.  auditory  canal,  membrana  tympani,  ana 
middle  ear ;  B,  second  ganglion  of  vagr.s  ;  C,  first  cervical  ganglion  of  sympathetic ;  D,  auriculo- 
pneumo-gastric  nerve  ;  E,  sympathetic  fasciculus  connecting  B  and  C ;  F,  ner^d  moUes,  vasomotor 
connection  with  external  carotid ;  G,  external  carotid ;  H,  larj-ngeal  artery ;  S,  superior  larj'ngeal 
nerve ;  L,  larynx. 

again  through  the  nervi  molles  carries  the  impression  to  the  external 
carotid  artery,  and  by  its  branches  to  the  mucous  membrane  of  the 
larynx,  and  as  a  result  of  reflected  vaso-dilator  impressions  we  may  have 
congestion  of  the  vessels  supplying  the  mucous  membrane  of  the  larynx, 
and  perhaps  effusion  from  these  vessels. 

The  detailed  description  of  the  anatomical  conditions  underlying  these 
reflex  phenomena  will  be  found  on  page  632. 

PAROXYSMAL  GASPING. 

A  condition  known  as  paroxysmal  gasping  occasionally  occurs  in 
young  children,  especially  in  girls. 

The  child,  previously  quiet,  suddenly  becomes  cyanotic,  rolls  up  its 
eyes,  stops  breathing,  gasps,  and  looks  as  though  it  were  about  to  die. 
The  seizure  is  apparently  a  reflex  irritation  of  the  diaphragm,  and  could 
be  classed  under  hysteria.  These  cases  respond  quite  readily  to  good 
care,  well-regulated  food,  and  relief  from  the  duties  of  school.  In  some 
cases  there  are  no  serious  symptoms,  but  mere  gasping  of  light  grade. 


REFLEX  SYMPTOMS  OP   THE  LUNG. 
In  young  infants  pulmonary  attacks  closely  simulating  the  symptoms 
of  asthma  occur  from  gastric  irritation  of  the  terminal  filaments  of  the 


DISEASES   OF  THE  NERVOUS   SYSTEM.  969 

pneumogasfric  nerve.  They  are  evidently  reflex  in  their  character,  and 
are  promptly  relieved  by  treatment  of  the  stomach.  They  are  spoken  of 
under  the  term  asthma  dyspepticum.  In  cases  of  this  kind  it  is  usually 
found  that  the  peripheral  irritation  either  arises  from  the  too  high  per- 
centages of  the  solid  constituents  of  the  milk  which  is  given  to  the  infant, 
or  is  caused  by  the  total  amount  of  milk  given  being  too  great  for  the 
infant's  gastric  capacity. 

Symptoms. — ^The  first  symptoms  noticed  in  these  cases  are  the  pallor 
of  the  infant's  face,  and  a  slight  cyanosis  around  the  mouth.  The  respi- 
rations then  become  quickened,  and  the  infant  is  evidently  in  great  dis- 
tress, it  becomes  cyanotic,  breathes  very  rapidly,  and  often  looks  as 
though  it  were  about  to  die.  On  examining  the  chest  the  lung  is  found 
to  be  resonant,  and  there  is  nothing  abnormal  on  auscultation  except 
roughened  respiration  and  a  few  sonorous  rales. 

Treatment. — An  emetic  will  quickly  relieve  this  condition,  which  disap- 
pears as  soon  as  the  stomach  is  emptied.  The  attacks  are  sudden  and  often 
recur.  After  the  attack  has  passed  off,  the  abnormal  sounds  heard  in  the 
lung  are  found  to  have  disappeared  completely,  and  the  infant  seems  per- 
fectly well  again. 

Another  class  of  reflex  pulmonary  symptoms  which  has  at  times  come 
under  our  notice  consists  of  cases  in  which,  from  some  peripheral  irritation 
elsewhere,  marked  pulmonary  symptoms  simulating  pneumonia  arise. 

The  first  case  was  a  little  girl  six  years  old.  The  first  attack  occurred  at  a  time 
when  she  was  having  an  exacerbation  of  an  attack  of  subacute  purulent  otitis  media. 
She  had  a  heightened  temperature,  40°  C.  (104°  F.),  and  rapid  respirations  (60  in  a 
minute).  The  alge  nasi  were  moving  slightly,  and  she  showed  a  certain  amount  of  or- 
thopnoea.  Her  face  was  flushed,  and  she  had  a  short,  dry  cough.  She  had  a  discharge 
of  pus  from  both  ears.  On  looking  at  this  child  one  would  naturally  have  said  that 
she  had  pneumonia.  Evidence  of  this  was  given  by  the  temperature,  the  respirations, 
the  alEe  nasi,  the  cough,  and  the  orthopnoea.  The  lungs,  heart,  and  throat  were  found 
on  examination  to  be  normal.  The  pulmonary  symptoms  were  evidently  reflex  in  their 
nature,  as  it  is  believed  that  in  these  cases  the  reflex  symptoms  are  usually  produced 
by  the  occlusion  of  the  Eustachian  tubes. 

On  inflating  the  Eustachian  tubes  with  the  air-douche  her  breathing  became  nor- 
mal in  rate,  24  to  28  in  a  minute,  the  alte  nasi  ceased  to  move,  the  cough  disappeared, 
and  the  child  could  lie  down  with  comfort. 

REFLEX  COUGH. 
The  nervous  connection  between  the  ear  and  the  larynx  gives  rise  at 
times  when  there  is  disease  of  the  former,  such  as  an  otitis  media,  to  a 
persistent  cough,  wliich  is  evidently  reflex,  and  which  is  relieved  only  by 
treatment  of  the  ear. 

A  little  girl,  four  years  old,  had  an  attack  of  measles  which  was  complicated  by  an 
otitis  media.  She  recovered  entirely  from  the  measles,  and  seemed  pei-fectly  well, 
except  that  the  perforation  of  the  membrana  tympani  had  not  entirely  healed.  Some- 
what later  the  cough  began.     Nothing  was  found  to  account  for  this  symptom  in  the 


970  PEDIATRICS. 

Ihroat,  lung,  or  larynx,  except  a  slightly  reddened  appearance  of  the  latter  from  cough- 
ing. The  cough  was  intractable  to  all  local  treatment  until  the  ear,  which  had  been 
in  the  process  of  healing,  again  showed  signs  of  increased  inflammation.  Whenever 
the  ear  was  discharging,  the  cough  ceased  entirely  When  the  ear  was  treated  and  the 
discharge  grew  less,  the  cough  began  again,  and  there  was  an  evident  reflex  connection 
between  the  larynx  and  the  ear. 

These  reflex  phenomena  continued  for  some  months,  the  child  always  coughing 
when  the  ear  got  better  and  ceasing  to  cough  when  the  ear  got  worse.  Finally,  on 
the  child's  being  taken  to  Switzerland  and  having  an  entire  change  of  air,  its  general 
health  Avas  much  improved,  and  the  reflex  cough  passed  off.  There  was  no  recurrence 
of  this  condition  in  the  folloAving  ten  years. 

When  there  is  an  irritation  in  the  naso-pharynx  a  reflex  cough  often 
occurs,  and  is  best  treated  by  local  applications  to  the  pharynx  and  naso- 
pharynx. It  is  important  for  the  physician  to  recognize  this  class  of 
coughs,  as  he  might  otherwise  be  very  unsuccessful  in  treating  these  cases. 
Many  cliildren  are  treated  with  drugs  for  a  cough  which  is  usually  ascribed 
to  broncliitis,  where  no  physical  signs  of  irritation  can  be  found  in  the 
lung,  larynx,  or  throat,  and  where  the  irritation  is  in  the  nose  or  the  naso- 
pharynx. In  place  of  the  many  drugs  usually  given  in  these  cases,  a 
simple  application  of  oil  to  the  nose  is  indicated.  Benzoinol  or  liquid 
albolene  are  used  for  this  purpose.  Two  or  three  minims  should  be 
dropped  into  each  nostril  by  means  of  a  medicine  dropper. 

REFLEX   SYMPTOMS   OF   THE   HEART. 

Cases  of  extreme  palpitation  in  children  are  occasionally  met  with 
when  notliing  oi^anic  can  be  detected,  and  when  no  cause,  such  as  tea- 
drinking,  is  discoverable.  The  children  are  of  a  highly  neurotic  temper- 
ament, and  are  usually  much  influenced  by  exciting  surroundings  in  their 
homes. 

A  boy,  ten  years  old,  was  subject  to  fits  of  great  excitement  brought  on  by  the 
most  trivial  causes,  such  as  preparing  to  go  to  school  or  to  take  a  journey.  For  some 
hours  before  the  proper  time  for  starting  came  he  was  apt  to  grow  more  and  more  agi- 
tated. He  would  then  often  be  seized  with  violent  palpitation  lasting  for  several  hours 
and  forcing  him  to  lie  perfectly  still  on  his  back.  At  these  times  his  skin  was  cool  and 
pale,  and  his  pulse  weak  and  irregular.  Nothing  abnormal  was  detected  on  an  exam- 
ination of  the  heart  or  any  other  organ.  The  attacks  lasted  until  he  was  twelve  years 
old,  and  have  never  occurred  since. 

REFLEX  SYMPTOMS  OF  THE  STOMACH. 
There  are  a  number  of  reflex  conditions  connected  with  the  stomach 
arising  from  different  causes  but  represented  by  the  same  symptom, 
vomiting.  Instances  of  this  condition  are  those  cases  of  vomiting  which 
arise  from  irritation  of  the  larynx  and  pharynx  and  which  are  cured  by 
local  applications  made  to  these  parts.  It  is  common  in  difficult  dentition 
and  in  these  cases  is  controlled  by  the  use  of  bromides  and  the  regulation 
of  the  food. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  97I 

BEFLBX   SYMPTOMS   OF  THE  BLADDER. 
Reflex  spasm  of  the  bladder  occurs  very  frequently  in  young  children, 
and  this  condition  has  been  described  under  enuresis,  page  877. 

REFLEX  SYMPTOMS  OF  THE  VAGINA. 
There  is  almost  always  a  direct  cause  to  be  found  for  the  reflex 
nervous  symptoms  which  arise  from  vaginal  irritation.  One  of  the  most 
common  causes  is  the  oxyuris  vermicularis,  which  at  times  gives  rise  to 
extreme  and  severe  symptoms  when  it  has  migrated  from  the  rectum.  In 
addition  to  the  local  irritation,  which  causes  the  child  great  uneasiness,  so 
that  it  cannot  sit  still  and  is  continually  movmg  its  legs  about,  its  tem- 
perament may  be  much  affected.  A  child  with  this  trouble  is  apt  to  be 
very  fretful,  to  have  violent  outbursts  of  temper,  to  lose  its  appetite,  and 
to  grow  thin. 

A  little  girl,  five  years  old,  had  the  most  extreme  vaginal  irritation.  When  we  saw 
her  she  had  been  affected  for  several  months  and  was  in  a  very  weak  condition.  At 
times  the  irritation  seemed  to  be  more  than  she  could  bear,  so  that  she  would  lose  all 
control  of  herself,  would  throw  herself  on  the  floor,  and  would  have  violent  spasmodic 
contractions  of  the  legs.  Her  sleep  was  much  interfered  with,  and  her  whole  appear- 
ance was  that  of  a  child  suffering  from  some  serious  disease.  An  examination  showed 
that  the  oxyuris  vermicularis  was  the  cause  of  the  vaginal  irritation,  and  .after  a  few 
days'  treatment  directed  to  the  expulsion  of  the  parasite  the  child  ceased  to  have  any 
irritation  and  subsequently  recovered  entirely. 

REFLEX   SYMPTOMS   OF   THE   RECTUM. 
In  certain  cases  reflex  symptoms   of  a  most  exaggerated  t)^e   are 
localized  in  the  rectum.     The  following  cases  are  illustrative  ; 

A  girl,  four  years  old,  had  always  been  remarkably  strong  and  robust,  and  had 
never  had  any  especial  local  trouble  with  the  bladder  or  the  rectum.  She  was,  how- 
ever, of  an  excessively  nervous  temperament,  and  was  surrounded  by  exciting  in- 
fluences in  her  home.  She  began  to  have  spasmodic  contractions  of  the  sphincter  ani. 
When  she  attempted  to  have  a  movement  of  the  bowels  it  frightened  her,  and  she 
would  clutch  at  any  piece  of  furniture  which  happened  to  be  near  her  and  try  not  to 
have  the  movement.  She  would  scream  and  cry  out  as  if  she  were  in  much  pain.  An 
examination  under  ether  showed  nothing  abnormal  in  the  rectum  or  sphincter,  such  as 
from  pressure  or  from  lesions,  and  the  condition  was  apparently  simply  that  of  spasm. 
She  was  treated  by  the  daily  dilatation  of  the  sphincter  ani  with  bougies,  the  size 
being  increased  gradually.  This  was  followed  by  marked  improvement,  and  the 
rectal  spasm  passed  away. 

Although  the  rectal  spasm  did  not  return  in  this  case,  yet  in  its  place  the  child 
began  to  have  incontinence  of  urine. 

Another  child,  eight  years  old,  for  a  whole  year  was  affected  by  intense  irritation 
in  the  region  of  the  anus,  which  prevented  her  from  sitting  down  for  any  length  of 
time  and  kept  her  in  a  continual  state  of  irritability.  Nothing  could  be  detected 
during  this  period  which  caused  these  symptoms.  No  trace  of  intestinal  parasites 
could  be  found,  and  nothing  abnormal,  either  at  the  anal  orifice  or  in  connection  with 
the  bowels,  was  seen,  the  skin  around  the  anus  being  in  a  perfectly  normal  condition. 
The  child  was  treated  with  bromide  of  potassium  for  several  weeks,  and  recovered  en- 
tirelv. 


972 


PEDIATRICS. 


CEREBRAL  ABSCESS. 
Cerebral  abscess  is  a  localized  purulent  encephalitis  and  is  probably 
always  secondary  to  suppurative  disease  elsewhere.  It  may  arise  from 
a  suppurative  condition  of  the  scalp,  but  its  most  common  source  is 
some  purulent  disease  of  the  ear  or  adjacent  structures.  Its  usual 
location  is  in  the  temporal  lobe,  just  over  the  tegmen  tympani  or  in 
the  cerebellum.  It  is  also  found  as  a  sequel  to  traumatism  of  various 
kinds  resulting  in  suppuration  and  in  general  pyaemia,  and  it  may  follow 
direct  traumatic  injury  to  the  brain.  Cerebral  abscess  is  usually  single, 
except  when  it  is  produced  by  pyaemia.  The  abscess  may  occur  in  any 
part  of  the  brain.     Cerebellar  abscess  is  not  uncommon. 

Symptoms. — A  cerebral  abscess  may  exist  for  a  considerable  time 
without  producing  any  symptoms  which  can  be  recognized  during  life. 
In  cases  m  which  suppurative  disease  of  the  ear  exists,  a  cerebral  abscess 
may  be  suspected  when,  in  addition  to  the  temperature,  which  would 
naturally  be  raised  from  this  process,  the  child's  general  condition  be- 
comes worse  without  any  apparent  cause,  and  when  indefinite  symptoms, 
such  as  mental  dulness  and  irritability,  arise.  The  temperature  and 
marked  leucocytosis  may  also  suggest  the  presence  of  imprisoned  pus, 
and  the  probability  of  cerebral  disease,  in  cases  in  which  the  pus  cannot  be 
found  elsewhere.  Cerebral  abscess,  however,  usuahy  exists  without  rise 
of  temperature,  or  even  with  a  subnormal  temperature  and  without  any 
increase  in  the  white  count.  It  is  apt  to  be  slow  in  its  progress  and  to 
cause  general  constitutional  rather  than  local  symptoms.  Local  symp- 
toms produced  by  the  presence  of  cerebral  abscess,  as  a  rule,  are  absent, 
but  may  be  manifested  by  sensory  aphasia  if  the  left  temporal  lobe  is 
involved,  or  in  the  case  of  cerebellar  disease  by  hemiataxia,  nystagmus, 
tendency  to  walk  or  fall  to  one  side,  diminished  or  increased  tonicity  of 
the  muscles  on  the  same  side  according  to  whether  the  lesion  acts  in  an 
^ — -irritative  or  paralytic  manner.  General  symptoms  of  brain  abscess  are 
represented  by  headache,  vertigo,  dimness  of  vision  caused  by  optic 
neuritis,  mental  dulness,  vomiting,  slow  pulse,  foul  breath  and  convulsions, 
fohowed  later  by  coma.  When  the  abscess  bursts  into  the  ventricles,  symp- 
toms of  collapse  appear,  and  death  rapidly  follows.  Tremor  and  convul- 
sions may  occur  in  cases  of  cerebral  abscess,  but  neither  of  them  should 
be  considered  as  in  any  way  symptomatic  of  this  condition.  An  abscess  of 
the  brain  may  remain  latent  for  a  long  time  and  suddenly  become  active. 

Prognosis. — The  prognosis  is  very  unfavorable  unless  the  disease  can 
be  reached  surgically. 

Treatment. — The  treatment  should  be  operative  if  the  diagnosis  can 
be  made  with  certainty. 

CEREBRAL  PARALYSIS  (Infantile  Cerebral  Palsies). 
In  using  the  term  cerebral  paralysis  it  must  be  understood  that  it  is 
not    intended  to   describe   every   disease   of   intra-cranial    origin    from 


DISEASES   OF   THE   NERVOUS   SYSTEM.  973 

which  a  paralysis  may  result.  We  may  have  a  paralysis  from  many 
intra-cranial  lesions,  such  as  hydrocephalus,  cerebral  abscess,  cerebral 
tumors,  and  other  causes.  These  conditions  are  not  included  in  the  class 
of  cases  designated  as  cerebral  paralysis  or  infantile  cerebral  palsies,  which 
are  motor  disturbances  arising  from  certain  cerebral  lesions,  occurring  in 
intra-uterine  life,  during  labor  or  after  birth  in  the  first  three  or  four 
years. 

There  is  much  concerning  the  definite  pathology  of  this  class  of  cases 
which  is  still  undetermined,  so  that  they  will  be  more  clearly  understood 
if  discussed  as  a  group  and  their  prominent  features  compared  with  each 
other.  This  is  all  the  more  necessary  as  the  clinical  manifestations  of 
all  of  them  are  practically  the  same,  and  are  represented  by  a  spastic 
paralysis  involving  one  or  more  extremities  in  the  form  of  a  hemiplegia, 
a  diplegia,  or  a  paraplegia.  Monoplegias  are  rare  in  comparison  with  the 
other  forms.  Any  one  of  these  forms  may  be  accompanied  by  contrac- 
tures, choreiform  movements,  mental  impairment,  epilepsy,  and  a  number 
of  similar  nervous  symptoms  usually  spoken  of  as  post-paralytic. 

In  225  cases  analyzed  by  Peterson  and  Sachs,  right  hemiplegia  oc- 
curred in  81  cases,  left  hemiplegia  in  75,  diplegia  in  39,  and  paraplegia 
in  30. 

Etiology. — The  cause  of  cerebral  paralysis  occurring  in  intra-uterine 
life  has  not  been  definitely  determined,  and  our  knowledge  concerning 
this  class  of  cases  is  very  vague.  It  has,  however,  been  found  that 
instances  not  infrequently  arise  in  which  there  is  an  hereditary  history  of 
epilepsy,  insanity,  or  marked  neuroses.  Traumatism,  severe  illnesses,  and 
fright  in  the  mother  are  accepted  as  other  possible  causes.  According  to 
Sachs,  syphilis  does  not  play  the  important  part  in  the  etiology  of  intra- 
uterine palsies  which  has  been  given  to  it  by  some  authors. 

The  cerebral  paralysis,  which  is  the  result  of  conditions  occurring 
during  labor  (birth-palsies),  may  arise  from  asphyxia  in  tedious  and  pro- 
longed deliveries,  which,  according  to  Sachs,  are  more  disastrous  than  the 
accidents  which  at  times  occur  when  the  forceps  are  used. 

Certain  etiological  factors  are  well  recognized  as  causes  of  the  palsies 
which  occur  after  birth  in  the  early  years  of  life.  These  are  traumatic 
injury  to  the  skuH,  fright,  the  acute  infectious  diseases,  such  as  mumps, 
measles,  scarlet  fever,  typhoid  fever,  variola,  pneumonia,  and  cerebro- 
spinal meningitis,  which  give  rise  to  areas  of  acute  encephalitis.  It  has 
also  followed  acute  tonsillitis,  severe  cases  of  gastro-enteric  disease,  per- 
tussis, and,  in  certain  instances,  violent  convulsions,  though  in  most  cases 
of  the  latter  condition  the  convulsions  are  probably  caused  by,  rather 
than  causative  of,  the  lesions  producing  the  paralysis. 

In  some  cases  the  disease  arises  in  apparently  healthy  children  and 
without  assignable  cause. 

Pathological  Anatomy. — In  the  intra-uterine  cases  the  lesions,  ac- 
cording to   Sachs,   are   represented   by  large    cerebral    defects   {poren- 


974  PEDIATRICS. 

cephaJy),  and  also  by  a  condition  designated  "  agenesis  corticalis,'"  in  which 
tliere  is  a  defective  development  of  the  cellular  elements  of  the  cortical 
and  particularly  of  the  pyramidal  cells,  which  is  not  restricted  to  any 
one  part  of  the  brain,  but  involves  all  parts  of  the  hemispheres  about 
equally. 

In  the  cases  which  occur  during  labor,  birth-jxilsies,  the  primary  lesion 
is  usually  a  meningeal  hemorrhage  (rarely  intercerebral),  and,  as  shown 
by  McNutt,  more  or  less  diffuse  over  both  hemispheres. 

In  all  cases  a  distinction  must  be  made  between  the  primary  lesions 
and  the  secondary  conditions. 

In  a  series  of  78  autopsies  in  infantile  hemiplegia  analyzed  by  Peter- 
son and  Sachs,  there  were  found  as  primary  lesions,  hemorrhage  23, 
embolism  7,  thrombosis  5,  and  tubercle  1  ;  while  as  secondary  lesions 
there  were  atrophy,  sclerosis,  and  cysts  40,  and  porencephalus  2.  Poren- 
cephalus  denotes  a  pathological  loss  of  substance,  forming  cavities  or 
cysts  running  from  the  cortex  of  the  brain  towards  the  centre,  affecting 
the  motor  region  and  being  either  unilateral  or  bilateral.  Sclerosis  con- 
sists of  a  shrinking  and  hardening  of  the  cerebral  tissues,  usually  more  or 
less  strictly  localized. 

Although  the  primary  lesions  of  all  forms  of  the  infantile  cerebral 
palsies  may  be  caused  by  embolism  or  thrombosis,  yet  these  etiological 
factors  are  rare  in  comparison  with  hemorrhage,  which  is  the  most  com- 
mon cause  of  the  primary  acute  symptoms.  This  hemorrhage  is  more 
apt  to  be  meningeal  than  capsular,  owing  to  its  traumatic  origin,  and  is 
usually  in  the  subarachnoid  space,  thus  differing  from  cerebral  hemorrhage 
in  the  adult,  which  occurs  more  frequently  in  the  region  of  the  internal 
capsule,  and  is  a  result  of  diseased  arteries.  Some  authorities  hold  that 
many  typical  cases  of  infantile  cerebral  paralysis  are  due  to  acute  infectious 
encephalitis,  especially  in  those  cases  characterized  at  the  onset  Avith 
repeated  convulsions  with  continued  high  fever. 

Thrombosis  may  be  a  cause  where  changes  have  taken  place  in  the 
cerebral  arteries  due  to  hereditary  syphilis,  and  embolism  may  be  the 
cause  in  such  predisposing  affections  as  valvular  cardiac  disease. 

The  pathology,  therefore,  of  the  condition  as  a  whole  is  a  lesion  of  the 
motor  tract  followed  by  atrophy  and  retarded  development  of  the  part 
affected,  and  a  descending  degeneration  of  the  pyramidal  tracts.  It  is  also 
possible  that  the  primary  cause  of  the  disease  may  be  a  defective  develop- 
ment of  the  nervous  centres. 

Symptoms. — If  the  lesion  has  been  of  intra-uterine  origin,  we  may  get 
only  the  later  manifestations,  just  as  in  congenital  syphilis.  The  paral- 
ysis in  this  class  of  cases  is  usually  diplegic  or  paraplegic,  and  mental 
enfeeblement,  amounting  often  to  idiocy,  is  common.  When  the  paraly- 
sis is  due  to  defective  cortical  development  the  muscles  may  be  flaccid 
instead  of  the  characteristic  spastic  condition  of  the  other  forms  of  cere- 
bral  paralysis.     If  the  lesion  has  occurred  at  the  time  of  delivery,  the 


DISEASES    OF    THE    NERVOUS   SYSTEM.  975 

primary  symptoms  are  often  masked,  and  the  resulting  symptoms  of  the 
more  advanced  pathological  condition  are  noticed  later. 

The  diagnostic  early  symptoms  are  paralysis,  convulsions,  rigidity, 
and  stupor  ;  asphyxia  and  irregular  respirations  are  common  symptoms. 
The  symptoms  vary  with  the  extent  and  locality  of  the  lesion.  There 
may  be  bulging  of  the  fontanelle,  changes  in  the  pupils,  and  oscillation  of 
the  eyeballs. 

When  the  disease  develops  in  extra-uterine  life  it  is  usually  acute  in 
its  character  and  is  marked  by  more  or  less  fever,  convulsions,  and 
stupor.  These  early  symptoms  are'  merely  those  of  a  general  nervous 
explosion  following  an  irritation  of  the  nervous  motor  centres.  They 
may  be  the  first  manifestations  of  a  disease  of  any  kind,  or  they  may 
occur  in  the  course  of  one  of  the  diseases  of  which  we  have  spoken  under 
etiology.  If  they  happen  to  occur  at  night  and  are  of  short  duration, 
they  may  be  entirely  overlooked,  and  the  later  symptoms  of  a  cerebral 
lesion  may  be  the  first  ones  to  manifest  themselves.  The  child  may  die 
from  the  severity  of  these  initial  lesions  before  the  later  symptoms  of 
paralysis  have  developed  by  which  we  can  diagnosticate  the  disease. 
Screaming,  vomiting,  and  delirium  may  at  times  usher  in  the  attack.  In 
the  midst  of  or  closely  following  these  primary  symptoms  come  the  pro- 
nounced indications  of  a  central  nervous  lesion,  represented  by  hemi- 
plegia (paralysis  of  an  arm  and  a  leg  on  the  same  side),  paraplegia 
(paralysis  of  both  legs),  or  diplegia  (paralysis  of  corresponding  parts  on 
the  two  sides  of  the  body),  forming  most  of  the  cases  of  "  Little's  disease." 
In  rare  cases  we  find  only  one  extremity  affected  (monoplegia).  Hemi- 
plegia is  by  far  the  most  common  form. 

In  addition  to  the  paralysis  of  the  limbs,  facial  paralysis  may  occur 
either  in  hemiplegia  or  in  diplegia,  and,  as  a  rule,  spares  the  upper  part 
of  the  face,  so  that  the  eyes  can  be  closed  and  the  brows  raised,  thus 
showing  that  it  is  not  a  peripheral  facial  paralysis.  This  form  of  facial 
paralysis  often  disappears  early.     Strabismus  is  common. 

On  examining  the  paralyzed  limb  we  find  a  resistance  to  motion,  the 
deep  reflexes  are  exaggerated,  and  in  most  cases  there  is  a  feeling  of 
rigidity  on  the  paralyzed  side.  A  few  cases  of  flaccid  paralysis  have 
been  reported.  Sensation,  as  a  rule,  is  not  affected.  When  the  child 
has  come  out  of  its  stupor  and  the  convulsions  have  ceased,  it  may  be 
found  to  be  aphasic,  but  aphasia  is  not  so  common  as  in  the  cerebral 
lesions  of  adults.  The  intelligence  is  usually  impaired,  but  this  depends 
upon  the  extent  and  location  of  the  lesion  and  the  period  when  it  occurred. 

The  intra-uterine  and  early  infantile  cases  show  the  greatest  mental 
disturbance.  These  children  are  apt  to  be  very  irritable,  and,  when  the 
lesion  is  cortical,  epileptiform  convulsions  are  quite  common.  The  mind 
may,  however,  remain  perfectly  clear  in  both  the  early  and  late  stages  of 
the  disease,  in  spite  of  a  marked  hemiplegia.  The  electrical  reaction  of 
the  muscles  is  normal.     In  the  more  advanced  stages  of  cerebral  paraiy- 


976  PEDIATRICS. 

sis  additional  symptoms  begin  to  appear.  The  child  learns  to  walk  late, 
or,  if  it  has  already  walked,  the  gait  becomes  peculiar.  Rigidity  fol- 
lowed by  contracture  of  the  flexor  and  abductor  muscles  occur.  In 
about  seventy-five  per  cent,  of  the  cases  of  diplegia  and  paraplegia  it 
comes  early  and  develops  oftener  than  in  the  adult  cases.  The  rigidity 
is  increased  by  manipulation  or  use  of  the  limb,  and  disappears  during 
sleep.  Post-hemiplegic  movements,  such  as  athetosis,  follow  in  a  certain 
number  of  cases ;  in  others  the  spastic  condition  is  so  pronounced  that  the 
patellar  tendon  reflex  and  the  ankle-clonus  cannot  be  obtained.  When 
walking  is  attempted,  the  palient  is  apt  to  stand  on  the  toes,  the  knees 
knock  together,  and  the  spastic  rigidity  of  the  muscles  produces  what  is 
cahed  the  spastic  gait,  represented  in  i!s  exaggerated  form  by  the  cross- 
legged  progression,  which  is  largely  caused  by  the  rigidity  of  the  abductors 
of  the  thigh.  Pes  equinus  and  pes  equino-varus  are  the  most  common 
deformities  of  the  foot.  When  the  arm  is  affected  with  contractures,  the 
fingers  are  pressed  into  the  palm  of  the  hand,  the  hand  is  flexed,  and  the 
arm  is  flexed  at  the  elbow  and  held  close  to  the  side. 

The  affected  hmbs  are  apt  to  show  some  disturbance  of  their  circula- 
tion, and  the  skin  is  cold  and  cyanotic.  There  are  more  or  less  atrophy 
and  shortening  of  the  bone,  but  to  a  less  degree  than  in  cases  of  polio- 
myelitis anterior.  In  a  certain  number  of  cases  involuntary  incoordinate 
movements  are  excited  in  the  paralyzed  limbs  on  voluntary  effort  (hemia- 
taxia),  and  are  usually  designated  as  post-hemiplegic  chorea.  There  may 
also  be  continuous  movements  (athetosis)  of  either  a  partial  or  a  general 
variety.  The  sphincters  are  not  affected,  whether  the  case  is  one  of 
hemiplegia  or  of  paraplegia.  Epileptiform  convulsions  may  appear  quite 
early  in  cases  of  cerebral  paralysis,  but  may  also  be  delayed  for  a  number 
of  years,  so  that  the  possibility  of  these  children  becoming  epileptic  must 
always  be  considered. 

Diagnosis. — The  diagnosis  in  a  marked  case  of  the  disease  is  not  diffi- 
cult, but  the  determination  of  the  exact  lesion  is  often  impossible  after 
the  period  of  onset  has  passed  and  we  are  left  with  a  resulting  paralysis. 
If  facial  paralysis  is  present,  we  can,  as  a  rule,  say  that  the  lesion  is  in 
the  brain ;  but  this  rule  does  not  always  hold  good,  as  there  have  been 
very  rare  cases  in  which  this  paralysis  was  present  when  the  lesion  was 
in  the  cord. 

The  symptoms  on  which  we  chiefly  rely  in  making  our  diagnosis  of 
cerebral  paralysis  are  (1)  the  distribution  of  the  paralysis,  hemiplegic, 
usually,  or  paraplegic ;  (2)  rigidity  of  the  muscles ;  (3)  increased  tendon 
reflex ;  (4)  comparatively  sAghi  wasting ;  (5)  normal  electrical  reaction ; 
and  (6)  mental  impairment.  Choreic  or  athetoid  unilateral  movements 
associated  with  a  slight  increase  of  tendon  reflex  point  towards  a  previous 
cerebral  paralysis. 

Ft-om  Poliomyelitis  Anterior. — The  principal  disease  from  which  cere- 
bral paralysis  is  to  be  distinguished  is  poliomyelitis  anterior.     In  contra- 


DISEASES   OF   THE   NERVOUS   SYSTEM.  97Y 

distinction  to  the  chief  diagnostic  symptoms  of  cerebral  paralysis  just 
stated  we  find  in  poliomyelitis  anterior  (1)  that  the  distribution  of  the 
paralysis  is  usually  monoplegic,  or  in  separate  groups  .of  muscles ;  (2) 
that  there  is  an  absence  of  tendon  reflex  ;  (3)  that  there  is  an  absence  of 
rigidity  in  the  early  stages  ;  (4)  that  there  is  rapid  and  marked  wasting  of 
the  alTected  limbs  ;  (5)  that  the  reaction  of  degeneration  is  present ;  and 
(6)  that  there  is  no  mental  impairment. 

From  Idiocy. — In  certain  cases  also  a  difficulty  may  arise  in  correctly 
understanding  the  relationship  between  cerebral  paralysis  and  idiocy. 
The  cerebral  lesion  is  in  many  cases  probably  the  same,  but,  according  to 
its  extent  and  location,  we  may  have  either  (1)  a  cerebral  paralysis  alone  ; 
(2)  a  cerebral  paralysis  accompanied  by  mental  impairment  or  idiocy ; 
or  (3)  idiocy  without  cerebral  paralysis.  There  is  a  certain  class  of  low- 
grade  idiots  in  which  some  impairment  of  motion  exists,  apparently  due 
to  a  mental  inability  to  co-ordinate  the  muscles  of  the  limbs  properly. 
This  may  sometimes  be  accompanied  by  a  diminution  of  sensation,  which 
seems  to  be  due  to  a  want  of  perception  in  the  higher  nervous  centres 
rather  than  to  any  actual  lesion  of  the  sensory  tract.  When  the  idiot's 
attention  can  be  kept  centred  on  the  limb,  the  actual  sensation  does  not 
seem  to  be  much  impaired.  The  differential  diagnosis  of  this  condition 
in  idiots  from  cerebral  paralysis  is  easily  made,  for  it  exists  only  in  those 
cases  of  idiots  in  whom  the  mental  development  is  much  impaired,  and 
it  is  not,  as  a  rule,  accompanied  by  true  paralysis,  as  there  is  no  weakness, 
but  simply  incoordination ;  in  these  cases  also  the  tendon  reflexes  are,  as 
a  rule,  not  increased. 

From  Caries  of  the  Spine. — Cerebral  paralysis  can  be  diagnosticated  from 
the  paralysis  which  occurs  in  connection  with  caries  of  the  spine,  princi- 
pally by  the  presence  of  cerebral  symptoms  in  one  case  and  the  promi- 
nence of  the  spinal  vertebrae  and  the  rigidity  of  the  spine  in  the  other. 

From  Syringomyelia. — Rare  cases  of  syringomyelia  may  be  mistaken 
for  cerebral  paralysis.  The  points  of  differential  diagnosis  in  these  cases 
are  that  in  syringomyelia,  although  the  weakness  of  the  limbs  may  be  so 
extensive  as  closely  to  simulate  paralysis,  yet  the  diminution  of  thermic 
sensation  easily  distuiguishes  it  from  the  normal  sensation  which  is  present 
in  cerebral  paralysis  in  cases  where  the  test  for  sensation  can  be  em- 
ployed. The  muscular  atrophy  is  also  much  more  pronounced.  Syringo- 
myelia, however,  is  so  rare  in  children  that  the  diagnosis  need  not  be 
dwelt  upon.     From  Obstetrical  Paralysis,  see  page  990. 

Prognosis. — In  the  intra-uterine  forms  of  cerebral  paralysis  a  large 
number  of  infants  die  at  varying  periods  during  the  early  months  of  Mfe, 
so  that  for  some  weeks,  at  least,  a  prognosis  as  to  life  cannot  be  given. 
Quite  a  large  number,  besides  developing  epilepsy,  also  show  the  condi- 
tion of  idiocy. 

A  severe  lesion  may  be  inferred  if  convulsions  occur  in  the  early  weeks 
and  if  apathy  continues  in  the  intervals  between  the  convulsions.     If  after 

62 


978  PEDIATRICS. 

a  few  weeks  or  months  the  convulsions  are  markedly  diminished,  and  if 
the  infant  begins  to  use  its  legs  and  to  take  notice  of  things,  a  more  favor- 
able prognosis  can  be  given.  So  long  as  contractures  do  not  develop  a 
fair  use  of  the  extremities  may  be  acquired.  Sachs  states  that  in  the 
intra-uterine  cases  diplegia  and  paraplegia  are  more  apt  to  be  associated 
with  cerebral  deficiency  and  epilepsy  than  is  hemiplegia. 

In  the  acute  extra-uterine  cases  the  prognosis  for  life  in  cerebral  paraly- 
sis is  soon  determined  in  the  early  days  of  the  attack,  and  depends  on  the 
location  and  extent  of  the  cerebral  lesion,  but  the  uncertainty  in  some 
cases  may  last  for  a  number  of  weeks.  On  account  of  the  usual  menin- 
geal form  of  the  hemorrhage  it  is  less  likely  to  prove  fatal  in  infants  than 
in  adults.  Entire  recovery  is  rare.  In  hemiplegia  the  paralysis  will  prob- 
ably improve.  The  spastic  rigidity  usually  goes  on  to  decided  contracture. 
In  some  cases  no  mental  change  is  apparent,  in  others  the  mental  devel- 
opment is  merely  retarded,  and  the  child  learns  to  talk  some  years  later 
than  is  normal.  In  a  large  number  of  cases,  however,  the  mind  is  much 
enfeebled.  The  occurrence  of  epilepsy  as  a  result  of  cerebral  paralysis 
is  so  common  that  it  should  be  especially  mentioned  in  this  connection, 
as  it  makes  the  prognosis  much  more  serious  both  as  to  the  degree  to 
which  the  mental  impairment  may  attain  and  as  to  the  life  of  the  patient. 

According  to  Gaudard,  Osier,  Wallenberg,  and  Sachs,  the  development 
of  convu.sions  after  an  infantile  apoplectic  attack  makes  it  probable  that 
chronic  epilepsy  ^^dll  result,  and  the  prognosis  becomes  mucli  more  grave. 
Statistics  show  that  epilepsy  follows  the  hemiplegic  cases  rather  more  fre- 
quently than  it  does  the  diplegic  and  paraplegic,  and  that  it  occurs  in 
about  half  the  cases  of  hemiplegia.  If  after  a  few  weeks  there  is  improve- 
ment, the  prognosis  is  good ;  if,  on  the  contrary,  there  is  no  improvement 
for  months,  it  is  bad.  In  some  cases,  however,  after  improving  for  even 
a  year,  convulsions  may  appear  and  epilepsy  develop.  Except  in  very 
rare  cases,  the  children  can  eventually  be  taught  to  walk.  In  many  in- 
stances,'although  during  infancy  there  is  complete  helplessness,  later  the 
condition  is  much  improved,  and  sometimes  considerable  activity  results. 

Treatment. — In  the  intra-uterine  cases,  as  it  is  the  later  manifestations 
of  the  disease  which  are  met  with,  the  treatment  should  be  the  same  as 
is  indicated  in  the  late  treatment  of  the  birth-palsies  and  of  the  extra- 
uterine cases.  In  acute  cases  the  infant  should  be  kept  perfectly  quiet, 
and,  if  unconscious  and  unable  to  nurse,  the  mother's  milk  or  a  carefully 
modified  milk  should  be  given  by  means  of  a  dropper.  If  convulsions 
appear,  small  doses  of  the  bromides,  0.18  to  0.48  gramme  (3  to  8  grains), 
or  chloral,  0.06  to  0.3  gramme  (1  to  5  grains),  and  inhalations  of  ether  are 
indicated,  and  in  protracted  convulsions  minute  doses  of  morphia,  0.0006 
gramme  (0.01  grain).  The  treatment  of  the  muscular  contractures  fol- 
lowing cerebral  paralysis  by  massage,  training,  tenotomy  or  apparatus  is 
of  the  greatest  importance,  and  should  be  referred  to  the  orthopaedic 
surgeon  as  soon  as  possible.     In  cases  occurring  at  birth  and  due  to 


DISEASES   OF   THE   NERVOUS   SYSTEM.  979 

hemorrhage,  operative  treatment  for  the  removal  of  the  blood-clot  has 
lately  been  done  with  success. 

Although  the  application  of  ice  to  the  back  of  the  neck  is  recom- 
mended when  a  cerebral  hemorrhage  is  suspected,  yet  in  young  infants 
this  procedure  should  be  used  with  great  caution,  as  cold  is  so  apt  to 
reduce  their  vitality. 

The  following  case  of  cerebral  paralysis  had  left  spastic  hemiplegia : 

The  boy  was  six  years  old.  The  dehvery  was  terminated  with  forceps,  but  the 
labor  was  not  a  severe  one,  and  he  was  healthy  at  birth.  He  developed  normally  for 
two  years,  and  walked  when  he  was  eighteen  months  old.  He  had  convulsions  in  his 
third  year,  and  these  convulsions  occurred  again  when  he  was  four  years  old.  They 
were  followed  by  paralysis.  He  could  not  use  his  left  hand  well,  and  the  grasp  of  the 
left  hand  was  less  strong  than  that  of  the  right.  The  triceps  reflex  was  exaggerated  on 
both  sides.  The  left  foot  could  with  difficulty  be  flexed  dorsally.  The  right  knee- 
jerk  Avas  normal,  the  left  increased.  He  had  flat-foot,  and  walked  with  his  left  foot 
inwardly  rotated.      He  was  otherwise  well  and  strong. 

The  follow^ing  case  represents  hemiplegia  of  traumatic  origin,  probably 
hemorrhage : 

A  girl,  four  years  and  nine  months  old,  was  brought  to  the  hospital  with  a  history  of 
having  fallen  from  the  roof  of  a  three-story  building  upon  a  brick  sidewalk.  She  was  un- 
conscious. She  vomited  slightly,  and  she  was  found  to  have  an  ecchmyosis  on  the  left  side 
of  her  head.  Her  pupils  were  equal  and  reacted  to  light.  Her  respirations  were  rapid  ; 
the  extremities  were  cold.  She  moved  all  her  limbs  vigorously.  Some  clotted  blood 
was  found  in  and  about  the  nostrils.  The  temperature  was  36.3°  C.  (97.4°  F.)  ;  the 
pulse  was  90,  and  the  respirations  were  26.  She  ground  her  teeth  and  cried  out  in 
the  night.     The  muscles  of  the  left  arm  and  leg  moved  actively. 

During  the  next  four  days  she  remained  unconscious.  Involuntary  micturition, 
inequality  of  the  pupils,  the  right  pupil  not  reacting  to  light,  irregular  pulse,  and 
slight  opisthotonos  developed  as  new  symptoms. 

On  the  seventh  day  she  appeared  brighter,  and  followed  objects  with  her  eyes.  Her 
pulse  was  irregular,  from  80  to  90. 

Two  days  later  she  made  voluntary  movements,  such  as  to  push  objects  away  from 
her,  and  gave  evidence  that  she  understood  what  was  said  to  her.  From  that  time  she 
slowly  improved. 

On  the  twenty-ninth  day  from  the  time  when  the  accident  occurred  she  could 
walk,  though  with  difficulty,  as  the  right  leg  was  very  unsteady.  One  week  later  she 
was  discharged  from  the  hospital.  She  could  then  use  the  right  arm  fairly  well,  but 
still  walked  with  some  difficulty  on  account  of  the  weakness  of  the  right  leg.  Her 
articulation  was  labored,  and  her  pupils  were  still  unequal. 

The  following  case  (Fig.  195)  represents  a  boy,  five  and  a  half  years 
old,  with  spastic  paraplegia  resulting  from  a  cerebral  paralysis  and  showing 
cross-legged  progression : 

The  cerebral  lesion  occurred  when  he  was  an  infant.  Nothing  abnormal  was 
noticed  about  him  until  he  was  fifteen  months  old,  when  it  was  observed  that  he  could 
not  walk.  He  had  more  or  less  mental  impairment,  nystagmus,  stiffness  of  the  ad- 
ductor and  flexor  muscles,  and  paralysis  of  the  extensors  of  the  lower  extremities. 
The  knee-jerks  were  much  increased,  and  there  was  slight  ankle-clonus.  He  walked 
in  the  characteristic  manner  called  cross-legged  progression. 


980 


PEDIATRICS. 


The  following  case  (Fig.  196)  represents  a  girl,  five  years  old,  affected 
with  diplegia  resulting  from  a  cerebral  paralysis  : 

She  had  a  good  family  history.  The  labor  was  easy,  and  was  not  instrumental. 
She  developed  well  and  was  healthy  until  she  was  ten  months  old,  when  it  was  noticed 
that  she  did  not  move  her  arms  as  she  ought  to,  that  she  did  not  use  her  left  arm  at 
all,  and  that  the  left  leg  was  not  used  as  well  as  the  right.     This  condition  persisted. 


Fig.   195. 


Fig.  196. 


Cerebral  paralysis.    Spastic  paraplegia.    Cross- 
legged  progression.    Male,  5)^  years  old. 


Cerebral  paralysis.  Diplegia.  The  left 
extremities  affected  more  than  the  right. 
Female,  5  years  old. 


She  had  strabismus.  She  could  not  hold  her  head  up  straight.  She  could  not  sit 
up  alone  or  stand.  Her  head  was  small  and  narrow,  and  had  a  long  antero-posterior 
diameter.  The  reflexes  were  increased.  The  power  of  her  left  arm  was  much  im- 
paired, and  thei'e  was  some  contraction  of  the  fingers  and  elbow  of  a  spastic  character. 
She  did  not  move  her  left  leg  well.  Sensation  was  dulled  alike  in  both  legs.  Her  face 
had  an  idiotic  expression,  she  was  poorly  developed  mentally,  and  she  could  not  talk. 

She  showed  the  form  of  spastic  cerebral  paralysis  which  is  called  diplegia,  the  left 
extremities  being  more  affected  than  the  right.    The  face  was  not  involved  in  this  case. 

The  prognosis  of  a  case  like  this  is  unfavorable  so  far  as  recovery  is  concerned,  on 
account  of  the  great  mental  impairment.  Operative  treatment  is,  however,  indicated, 
as  at  times  improvement  results  in  even  decidedly  idiotic  cases. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  981 

MYELITIS. 

The  term  myelitis  denotes  an  inflammation  of  the  spinal  cord,  whether 
of  the  gray  or  of  the  white  matter.  Acute  myelitis  has  been  used  to 
designate  an  acute  diffuse  inflammation  of  both  the  gray  and  the  wliite 
matter  of  the  cord  of  non-traumatic  origin,  and  is  an  affection  almost 
unknown  in  children. 

The  term  meningo-myelitis  is  used  to  denote  an  inflammation  of  the 
meninges  and  of  the  spmal  cord. 

Acute  myelitis,  meningo-myelitis.  and  hemorrhage  into  the  cord  are 
extremely  rare  in  early  life. 

INFANTILE   SPINAL,   PARALYSIS    (Poliomyelitis  Anterior  Acuta). 

Infantile  spinal  paralysis  is  the  most  frequent  and  therefore  the  most 
important  disease  which  affects  the  spinal  cord,  with  a  resulting  jDaralysis, 
in  infancy  and  early  childhood.  It  is  rare  in  the  first  six  months  of  life, 
and  occurs  most  commonly  m  the  first  three  years  of  life.  It  may  develop 
in  later  childhood,  and  rarely  in  adults.  It  is  met  with  more  commonly 
than  cerebral  paralysis,  and  is  represented  clinically  by  a  motor  paralysis 
rapidly  leading  to  atrophy  of  the  muscles  affected. 

Etiology. — The  disease  may  be  a  primary  infection  or  it  may  be 
apparently  secondary  to  other  diseases,  such  as  the  acute  exanthemata 
and  erysipelas.  Most  of  the  cases  occur  during  the  summer  months,  and 
at  night  rather  than  during  the  day.  It  attacks  healthy  children  as  well  as 
unhealthy.  It  is  not  hereditary.  It  occurs  not  infrequently  in  epidemics, 
and  is,  therefore,  supposed  to  be  infectious  in  its  origin,  but  no  specific 
organism  has  been  discovered.  Vincent  and  Beauchi  and  others  have  by 
inoculation  experiments  with  micro-organisms  caused  lesions  in  the  cord 
which  in  their  distribution  and  character  resemble  those  of  acute  poho- 
myelitis.  Painter  has  recently  reported  an  epidemic  of  32  cases  in 
Gloucester,  Mass.,  m  1901,  23  of  which  were  males  and  9  females.  The 
youngest  was  an  infant  of  thirteen  months.  It  is  very  rare  before  the  fifth 
month.     Most  of  the  cases  occur  m  the  second  and  third  years. 

Pathological  Anatomy. — ^Acute  anterior  poliomyelitis  consists  ol  an 
acute  inflammation  of  the  gray  matter  of  the  anterior  bones.  If  the  cord 
is  examined  soon  after  death  one  finds  hyperasmia  of  the  arteries  and 
often  thromboses,  hemorrhages,  leucocytes  and  especially  round-cell  infil- 
tration. The  ganglion  cells  are  cloudy  and  their  nuclei  indistinct.  The 
nerve  fibres  themselves  are  swollen.  Atrophy  of  the  ganglion  cells  and 
nerve  fibres  follows  as  a  result  of  these  changes  and  may  even  extend 
into  the  wliite  substance. 

The  circumference  of  the  limb  grows  small  in  comparison  with  that  of 
the  opposite  one,  being  the  result  of  an  active  muscular  wasting  and  of 
retarded  growth.  The  bones  of  the  affected  limbs  are  often  shorter  than 
those  of  the  other  side,  sometimes  even  to  the  extent  of  several  inches. 
In  certain  cases,  however,  the  lengths  of  the  bones  seem  to  be  but  little 


982  PEDIATRICS. 

altered,  although  the  atrophy  of  the  muscles  may  be  very  marked.  The 
anterior  cornua  at  the  site  of  the  lesion,  which  is  usually  in  either  the 
cervical  or  the  lumbar  enlargement,  are  greatly  atrophied  and  many  of 
the  large  motor  cells  are  destroyed.  The  affected  half  of  the  cord  may 
be  considerably  smaller  than  the  other,  and  the  anterior  lateral  column 
may  show  slight  sclerotic  changes,  chiefly  in  the  pyramidal  tract.  Accom- 
panying this  condition  the  corresponding  anterior  nerve-roots  are  atro- 
phied, and  the  muscles  connected  with  the  region  of  the  cord  which  is 
involved  atrophy  and  gradually  undergo  a  fatty  and  sclerotic  change. 

Symptoms. — The  onset  of  the  disease  in  the  great  majority  of  cases  is 
acute.  Its  recovery  is  protracted.  In  the  acute  form  the  onset  may  be 
preceded  for  some  days  by  fever  and  restlessness,  but  it  is  apt  to  appear 
suddenly  with  general  convulsions  which,  as  a  rule,  are  of  a  milder  type 
than  those  which  occur  in  cerebral  paralysis,  but  may  be  absent. 

Following  the  acute  onset  there  are  at  times  unconsciousness,  lasting 
sometimes  for  a  number  of  days,  vomiting,  general  nervous  disturbance 
of  the  bladder  and  intestines,  and  a  variety  of  symptoms  of  nervous 
irritability  which  may  simulate  the  prodromata  of  a  number  of  diseases. 
The  vomiting,  when  it  occurs,  accompanies  the  initial  fever,  resembles 
the  cerebral  type,  and  is  not  connected  with  gastric  disturbance.  Coma 
may  be  present,  but  is  rarer  than  convulsions,  and  is  not  usually  pro- 
found. The  temperature  is  seldom  very  high,  38.3°  to  38.7°  C.  (101°  to 
102°  F.) ;  it  may,  however,  in  certain  cases  be  higher.  At  times  no  pro- 
dromata are  observed,  but  the  paralysis  is  noticed  in  the  morning  after  a 
night's  rest,  although  on  the  evenmg  before  the  child  was  seemingly 
perfectly  well.  The  severity  and  length  of  the  prodromal  symptoms  are 
no  indications  of  the  gravity  of  the  lesion  or  of  the  prognosis  as  to 
recovery.  Pain  in  the  paralyzed  limb  is  not  an  uncommon  symptom.  It 
is  accentuated  by  handling  and  is  probably  due  to  an  associated  neuritis. 
The  temperature  of  the  limb  is  lowered,  the  skin  is  of  bluish  tinge  and 
the  muscles  flaccid.  The  disease  is  primarily  a  motor  disturbance, 
sensation  remaining  intact.  Cerebral  symptoms,  if  present,  pass  off 
rapidly  Avith  the  appearance  of  the  paralysis  which  is  usually  apt  to  affect 
more  than  one  limb  in  the  beginning,  but,  as  a  rule,  soon  becomes  mono- 
plegic.  The  leg  is  more  frequently  affected  than  the  arm.  Paraplegia 
in  the  beginning  is  not  uncommon,  and  all  forms  of  paralysis  may  occur. 
There  may  also  be  diplegia,  crossed  paralysis,  and  paralysis  of  the 
muscles  of  the  back  and  abdomen.  Hemiplegia,  so  common  and  almost 
characteristic  of  cerebral  paralysis,  may  be  present,  but  is  rare  in 
poliomyelitis  anterior.  The  muscles  most  frequently  affected  are  the 
extensors,  adductors,  and  supinators.  The  distribution  of  the  paralysis 
is  usually  in  groups  of  muscles.  The  respiratory  muscles  may  be  affected, 
although  rarely.  Facial  paralysis  is  so  uncommon  that  it  can  almost  be 
said  never  to  occur  in  uncomplicated  poliomyelitis.  When  the  initial  symp- 
toms have  passed  off,  as  they  usually  do  very  quickly,  the  functions  of  the 


DISEASES   OF   THE   NERVOUS   SYSTEM.  983 

body  are  carried  on  as  usual,  and  the  general  growth  and  mental  activity 
are  unimpaired.  The  tendon  reflexes  disappear  in  the  affected  limbs  when 
all  the  muscles  are  severely  affected.  "When  the  paralysis  has  reached  its 
height,  v^'hich  is  usually  in  a  few  hours  or  days,  it  remains  stationary  for 
perhaps  from  three  to  six  weeks,  and  then  gradual  improvement  begins,  and 
goes  on  m  certain  groups  of  the  paralyzed  muscles  for  six  or  eight  months, 
lea\ing  other  groups  paralyzed.  These  groups  again  at  times  recover  en- 
tirely or  remain  disorganized,  leading  later  to  contractures  and  deformities. 
When  contractures  occur  they  appear  later  than  do  those  of  cerebral  origin. 

"When  paralysis  affects  wholly  or  chiefly  the  gastrocnemii  and  posterior 
tibial  muscles,  the  other  groups  act  predominantly,  causing  dorsal  flexion 
of  the  foot,  so  that  the  child  walks  on  its  heel.  This  condition  is  termed 
talipes  calcaneus.  When,  on  the  other  hand,  the  tibialis  anticus  and  ante- 
rior muscles  of  the  leg  are  most  affected,  the  deformity  of  talipes  equinus 
occurs ;  and  if  the  peroneal  muscles  remain  unaffected,  there  is  valgus, 
while  if  they  are  affected  with  the  anterior  group,  talipes  equino-varus 
occurs.  There  may  be  dislocation  of  the  hip  in  rare  cases  of  complete 
paralysis  of  the  leg.  Severe  cases  may  shoAV  complete  flaccidity,  and  not 
infrequently  the  ligaments  about  the  joints  are  so  weakened  that  the 
joints  become  too  movable,  and  the  condition  called  flail-joint  results. 
This  condition  may  be  present  at  the  hip.  knee,  or  ankle,  and  sometimes 
at  the  shoulder  or  wrist.  Muscular  atrophy,  rapid  and  extreme,  is  the 
rule  in  pohomyelitis  anterior,  and  begins  a  few  weeks  after  the  appearance 
of  the  paralysis.  There  may  also  be  shortening  of  the  bones  from  arrest 
of  growth.  Spasmodic  movements,  except  the  primary  convulsions,  are 
absent.  The  sphincters  are  frequently  involved  at  the  onset  but  quickly 
resume  their  function.  In  rare  cases  improvement  immediately  follows 
attack,  going  on  to  complete  recovery  {iemporary  sjnnal  paralysis). 

In  the  epidemic  form  the  fever  is  apt  to  be  high,  the  distribution  of  the 
paralyses  extensive,  and  in  a  series  of  ten  cases  examined  by  Bracket! 
the  sphincters  were  at  times  involved,  and  in  the  severe  cases  prolonged 
hypersesthesia  occurred. 

Diagnosis.— In  the  stage  of  onset,  and  until  paralysis  has  appeared, 
the  diagnosis  must  be  held  in  abeyance.  The  salient  points  by  which  a 
diagnosis  can  usually  be  made  are  (1)  sudden  paralysis  ;  (2)  loss  of  tendon 
reflex ;  (3)  rapid  atrophy ;  (4)  cold,  flaccid  hmbs  ;  (5)  absence  of  impair- 
ment of  sensation ;  (6)  presence  of  the  reaction  of  degeneration. 

It  is  always  difficult  to  diagnosticate  poliomyelitis  in  the  initial  stage 
of  the  disease.  At  that  time  pain  and  sensitiveness  of  the  affected  lunb 
may  be  present,  and  may  lead  us  to  suspect  that  the  disease  is  rheuma- 
tism. The  convulsions  and  unconsciousness  which  may  appear  at  this 
sta^e  are  so  often  present  in  other  diseases  that  they  are  not  of  much  aid 
in  making  the  diagnosis. 

The  most  reliable  test  at  our  command  for  making  the  diagnosis  of 
poliomyelitis  anterior  is  the  electrical  reaction.      Nominally  fai'adism  or 


984 


PEDIATRICS. 


galvanism  to  a  nerve  gives  rise  to  contractions  of  the  muscles  which  it 
supplies.  Contractions  can  also  be  obtained  from  the  muscles  if  galvanism 
or  faradism  be  directly  applied  to  the  muscles  themselves.  When  the 
reaction  of  degeneration  is  present,  that  is  if  the  nerve  is  degenerated, 
galvanism  or  faradism  applied  to  the  nerve  no  longer  excites  muscular 
contractions,  nor  does  faradism  to  the  muscles  cause  contraction,  but  the 
muscles  still  respond  to  galvanism.  The  character'  of  the  contraction 
excited  by  galvanism  is,  however,  changed.  First,  it  requires  a  much 
weaker  current  to  produce  a  contraction ;  secondly,  the  character  of  the 
contraction  is  slow  and  more  diffuse  ;  and,  finally,  the  anode  closing 
contraction  is  greater  than  the  cathode,  reverse  of  normal  condition.  This 
reaction  of  degeneration  cannot  be  elicited  until  the  eighth  or  tenth  day. 

TABLE   73. 


Cerebral  Taralysis. 

Poliomyelitis  Anterior. 

Motor  disturbance 

Contractures 

Paralysis.  Most  common  form 
hemiplegia. 

Spastic  rigidity. 

Spastic  gait. 

All  the  muscles  of  a  limb  af- 
fected. 

Of  all  the  muscles,  especially 
the  flexors  and  adductors. 

Athetosis. 

Post-paralytic  chorea. 

Epileptiform  convulsions. 

UnaHected. 

Arrest  of  growth. 

Normal. 

Exaggerated  on  the  paralyzed 

side. 
Liable  to  be  impaired. 
Often  impaired. 

Paralysis.  Most  common  form 
monoplegia. 

Flaccid. 

Groups  of  muscles  in  a  limb 
affected,  usually  the  exten- 
sors. 

Of    muscles    antagonistic     to 

Spasmodic  movements  . . 
Sensation 

those  which  are  paralyzed. 
Absent. 
Convulsions  may  occur  at  the 

onset  of  the  disease. 
Unaffected. 

Nutrition 

Tendency  to  extreme  atrophy 

Electrical  reaction 

Tendon  reflex  

coming  on  early  in  the  para- 
lyzed limb. 

Reaction  of  degeneration. 

Absent. 

Speech. 

Unimpaired. 

Intelligence 

Normal. 

From  Cerebral  Paralysis. — Poliomyelitis  anterior  is  most  apt  to  be 
mistaken  for  cerebral  paralysis,  and  can  be  best  differentiated  from  that 
disease  by  means  of  the  symptoms  which  have  been  described. 

From  Maltiple  Neuritis.— T\].&  principal  points  by  w^hich  multiple  neu- 
ritis is  to  be  distinguished  from  poliomyelitis  anterior  are  {a)  the  sym- 
metrical affection  of  the  limbs  in  the  former  and  tenderness  over  the 
iierve-trunks ;  (b)  tlie  atrophy  in  multiple  neuritis  is  not  so  severe  as  in 
cases  of  pohomyeliLis  anterior ;  (c)  the  course  of  the  disease  is  different, 
cases  of  multiple  neuritis  almost  invariably  recovering,  while  severe  cases 
of  poliomyelitis  do  not  recover. 

From  Progressive  Central  and  Progressive  Neural  Muscular  Atrophies. 
—The  diagnosis  of  these  conditions  will  be  found  on  pages  1014  and  1016. 
■  FromPsetido-Hijpertrophic  Muscular  Dystrophies. — Pseado-hypertrophic 
muscular  paralysis  in  its  early  stage  is  not  likely  to  be  mistaken  for  polio- 
myelitis, but  in  the  later  stages  of  this  disease,  in  which  atrophy  may  occur, 
it  may  be  necessary  to  make  a  differential  diagnosis.     (See  page  1018.) 


DISEASES  OF  THE   NERVOUS   SYSTEM.  985 

From  Rhachitis. — In  certain  cases  of  rhachitis  the  power  of  using  the 
legs^is  so  much  affected  that  the  mistake  is  quite  commonly  made  of  sup- 
posing that  these  children  are  affected  by  poliomyelitis  anterior.  The 
condition  in  rhachitic  children  is  one  of  weakness  and  not  of  paralysis, 
and  can  be  distinguished  by  the  normal  electrical  reaction  of  the  muscles, 
by  the  presence  of  normal  reflexes,  and  by  the  lack  of  pronounced  atrophy. 

From  the  Pseudo- Paralysis  of  Scorbutus. — The  pseudo-paralysis  which 
is  commonly  seen  in  cases  of  scorbutus  is  often  mistaken  for  some  organic 
disease  of  the  central  nervous  system,  with  its  resulting  paralysis.  The 
differential  diagnosis  from  poliomyelitis  anterior,  however,  is  not  diffi- 
cult to  make,  for  the  involvement  of  other  joints  in  addition  to  those  of 
the  legs,  the  presence- of  pain  and  tenderness  to  such  a  degree  that  the 
child  cries  whenever  the  limbs  are  touched,  and  the  normal  temperature 
of  the  skin  distinguish  this  condition  from  poliomyelitis,  in  which  normal 
sensation,  absence  of  pain,  and  a  cold  feeling  of  the  limb  affected  are  found. 

Prognosis. — So  far  as  a  fatal  issue  is  concerned,  the  prognosis  is  very 
favorable.  If  death  occurs,  it  usually  takes  place  at  the  end  of  one  or 
two  weeks,  and  is  the  result  of  interference  Avith  respiration,  which  may 
be  caused  when  the  paralysis  is  extensive.  When  in  the  initial  stage  of 
the  attack  cerebral  symptoms  are  prominent  and  continue  for  some  time, 
the  prognosis  is  grave.  The  prognosis  is  not  so  good  in  the  epidemic 
form,  which  is  much  more  severe  in  its  manifestations. 

A  second  attack  of  the  disease  is  very  rare,  and  when  it  occurs  it 
usually  comes  a  few  days  after  the  original  attack,  and  manifests  itself  by 
an  increase  of  the  existing  paralysis.  The  paralysis,  as  a  rule,  will  not 
increase  when  it  has  been  stationary  for  twenty-four  hours.  The  tendency 
of  poliomyelitis  is  for  a  time  to  improve.  Some  of  the  limbs  affected 
recover  in  the  first  few  days,  but  if  the  paralysis  persists  longer  perfect 
recovery  is  rare.  When  there  is  no  improvement  after  six  or  eight 
months  the  probability  is  that  entire  recovery  will  never  take  place,  al- 
though under  proper  treatment  slight  improvement  may  go  on  for  years. 

We  must  remember  that,  even  when  untreated,  a  case  of  poliomyelitis 
is  very  apt  to  improve  for  one  or  two  months  quite  rapidly,  then  slowly 
for  two  or  three  months,  and  after  a  stationary  period,  contractures, 
looseness  of  the  joints,  and  malpositions  may  begin  to  be  evident  and 
may  increase  indefinitely.  The  cells  in  the  cord  which  are  destroyed  can 
never  be  replaced,  but  the  absorption  of  the  inflammatory  exudate  may 
allow  the  partially  impaired  cells  to  resume  their  function. 

When  proper  treatment  is  carried  out,  the  prognosis  is  much  more 
favorable,  and  the  period  of  possible  improvement  can  be  extended  for 
some  years.  According  to  Bradford  and  Lovett,  there  is  certainly  no 
leg,  however  wasted  and  contracted,  that  is  not  amenable  to  some 
improvement  by  operative  or  mechanical  treatment. 

Treatment, — The  treatment  of  poliomyelitis  by  means  of  drugs  has 
produced  such  unsatisfactory  results  that  it  may  be  said  to  be  useless. 


986  PEDIATRICS. 

At  the  onset  of  the  attack  the  bowels  should  be  freely  moved,  and  con- 
vulsions, if  present,  should  be  treated  symptomatically  (see  page  930). 

Although  Ave  know  of  no  rational  means  of  treatmg  the  primary 
lesion  of  poliomyelitis  anterior,  we  know  that  the  results  of  this  lesion, 
as  shown  by  paralysis  of  the  muscles,  are  such  that  the  paralysis  should 
be  treated  at  once.  The  indication  is  to  combat  the  rapid  atrophy  which 
is  part  of  the  disease,  and  to  prevent  its  increase  and  its  later  results 
from  proceeding  to  a  degree  which  would  interfere  with  subsequent 
repair.  To  accomplish  this,  the  affected  limb  should  be  supported  in  a 
normal  position  and  carefully  guarded  against  the  stretching  of  joints, 
ligaments,  and  muscles.  In  addition  to  this,  after  an  interval  of  two 
weeks,  gentle  massage  and  the  galvanic  current  applied  five  or  ten  min- 
utes at  a  time  at  least  four  or  five  times  a  week  are  indicated  to  keep  the 
affected  muscles  in  the  best  possible  condition  and  to  combat  the  atrophy 
which  to  a  greater  or  less  degree  occurs.  The  regular  application  of  heat 
is  also  found  to  be  useful  when  the  limb  is  cold.  Hot  fomentations 
followed  by  brisk  rubbing  with  a  coarse  towel  dipped  in  cold  water  is 
valuable  in  maintaining  the  nutrition  of  the  part.  The  muscles  are  less 
likely  to  contract  and  deformities  to  result  in  properly  supported  limbs. 

The  later  manifestations  of  club-foot  and  other  deformities  should  be 
dealt  with  by  the  orthopaedic  surgeon.  Tenotomy  may  be  employed  for 
late  contractures  and  the  transplantation  of  tendons  is  of  value  when 
natural  improvement  has  ceased.  Nerve  transplantation  has  lately  been  re- 
sorted to,  but  the  value  of  the  operation  has  not  yet  been  fully  determined. 

The  following  case  and  Fig.  197  represent  poliomyelitis  in  a  girl  nine 
years  old : 

She  was  perfectly  well  up  to  the  time  of  an  attack,  which  came  on  suddenly  and 
without  known  cause.  She  was  said  to  have  fallen  while  she  was  playing,  but  no 
injury  of  the  leg  could  be  detected,  although  she  was  carefully  examined  under  ether. 
The  exact  date  of  the  attack  was  not  known,  but  it  was  not  recent.  Her  general 
health  was  reported  to  have  been  very  good,  and  she  seemed  to  be  bright  mentally. 
She  was  well  developed,  and  had  a  good  color.  Nothing  abnormal  had  been  detected 
on  physical  examination  of  the  lungs,  thorax,  abdomen,  or  other  organs.  The  pulse 
was  regular  and  of  good  strength.  The  left  leg  showed  considerable  atrophy,  being 
4.37  cm.  (If  inches)  smaller  than  the  right  in  the  calf  and  2.5  cm.  (1  inch)  in  the 
thigh.  The  leg  was  somewhat  cyanotic,  and  was  cold  to  the  touch.  There  was  marked 
weakness  of  the  muscles  below  the  knee,  especially  the  extensors  of  the  foot  and  of 
the  toes.  When  she  was  lying  in  bed  the  movements  of  the  thigh  were  performed  with 
some  strength.  On  walking  she  rotated  the  leg  outward,  so  that  the  foot  was  at  right 
angles  with  the  line  of  motion,  and  she  dragged  the  toes.  The  joints  were  freely 
movable.  Nothing  abnormal  had  been  detected  in  connection  with  the  spine,  which 
presented  the  condition  of  a  movable  lateral  curvature,  due  to  the  shortening  of  the 
affected  leg.  As  the  primary  lesion  probably  occurred  some  years  previously,  the  prog- 
nosis was  bad  as  to  complete  recovery  or  much  improvement. 

Fig.  198  represents  a  girl,  two  and  one-half  years  old,  who  had  an 
attack  of  poliomyelitis  anterior  of  the  abdominal  muscles. 


DISEASES   OF   THE  NERVOUS   SYSTEM. 


987 


She  had  a  sister  who  was  said  to  have  had  an  attack  of  poliomyelitis  anterior  when 
she  was  ten  months  old.  No  other  history  had  heen  obtained  about  this  case,  except 
that  she  w^as  well  and  strong  until  this  attack,  which  occurred  six  weeks  preA-ious  to  the 
time  when  the  picture  was  taken.     The  onset  of  the  disease  was  sudden,  and  was 


Poliomyelitis  anterior.    Left  leg 
old. 


Female,  y  years 


Poliomyelitis  anterior.    Abdominal  muscles, 
left  side.    Female,  2>^  years  old. 


accompanied  by  high  fever,  followed  in  three  days  by  complete  paralysis  of  the 
muscles  of  the  upper  and  lower  extremities  of  the  body  and  of  the  head.  The  arms  and 
head  soon  recovered.  She  was  unable  to  sit  up  alone,  and  the  abdominal  muscles  Avere 
paralyzed  to  such  an  extent  on  the  left  side  that  they  were  flaccid,  bulged  out,  and  did 
not  react  normally.  The  left  leg  was  perfectly  flaccid.  The  knee-jerks  were  absent. 
The  surface  temperature  was  diminished,  and  there  was  atrophy  of  both  legs.  Under 
treatment  with  electricity  and  massage,  complete  recovery  took  place  in  this  case. 

Fig.  199  represents  the  condition  of  flail  leg  following  an  attack  of 
poliomyelitis  anterior. 

A  boy,  six  and  one-half  years  old,  was  apparently  healthy  at  birth,  and  had  never 
had  any  illness.     When  he  was  one  year  old  he  was  notrced  to  have  some  motor  dis- 


988 


PEDIATRICS. 


turbance  of  the  left  leg.  On  examination  of  the  leg  when  he  was  two  and  a  half 
years  old  the  surface  temperature  was  found  to  be  diminished,  the  knee-jerk  was  ab- 
sent, and  there  was  an  atrophy  of  5  cm.  (2  inches)  of  the  thigh  and  6.5  cm.  (2^ 
inches)  of  the  calf.  There  was  also  3.7  cm.  (1^  inches)  shortening  in  the  leg.  The 
child  Avalked  with  a  marked  limp  of  the  left  leg,  and  there  was  the  condition  of  flail- 
joint  in  his  left  knee  and  ankle.  This  was  a  typical  case  of  the  appearances  presented 
in  the  advanced  stages  of  a  severe  case  of  poliomyelitis  anterior. 


Ptg.    199. 


Poliomyelitis  anterior.    Flail  leg,  left 
side.    Male,  6)4  years  old. 


Poliomyelitis  anterior.    Talipes  equiuus 
ou' right  side.    Male,  ll>i  years  old. 


The  following  case  represents  diplegia  caused  by  poliomyelitis 


The  child,  a  girl  of  five  years,  was  well  and  strong  until  a])out  her  third  year, 
when  she  had  an  attack  of  whooping-cough.  During  this  attack  she  also  had  some 
other  illness,  which  was  characterized  by  fever  and  pain  in  the  back.  The  loss  of 
power  of  her  legs  dated  from  this  time,  and  is  said  to  have  been  gradual.  She  was 
fairly  well  deyeloped,  and  the  paralysis  had  affected  both  legs  and  thighs  as  well  as  the 
psoas  and  iliac  muscles.     There  was  marked  atrophy,  and  the  reflexes  were  absent. 

The  limbs  were  held  apart  and  were  flaccid.  If  the  case  had  been  one  of  cerebral 
paralysis  there  would  have  been  in  place  of  this  flaccid  condition  a  contraction  of  the 
adductors  of  the  thigh,  which  Avould  have  been  apt  to  hold  the  limbs  closely  together. 


DISEASES    OF   THE    NERVOUS   SYSTEM.  989 

Fig.  200  represents  a  boy,  eleven  and  a  half  years  old,  with  talipes 
equinus  following  acute  poliomyelitis  anterior. 

The  anterior  poiiion  of  tlie  foot  was  flexed  at  a  sharp  angle  at  the  iiiedio-Larsal 
joint.  The  foot  could  be  easily  bent  to  a  right  angle,  but  not  beyond.  Tense  bands 
of  plantar  fascia  could  be  felt  when  the  foot  was  straightened  out,  luit  it  could  be 
brought  into  position  by  the  use  of  considerable  force.  The  length  of  the  legs  was 
equal.  There  was  1  cm.  (about  |  inch)  atrophy  in  the  right  calf  and  0.6  cm.  (j  inch) 
of  the  right  thigh. 

This  condition  of  talipes  equinus  resulted  from  a  contraction  of  the  flexor  muscles 
following  an  attack  of  infantile  paralysis. 

PARALYSIS   CAUSED  BY  CARIES   OF  THE   SPINE. 

The  condition  resulting  from  compression  occurring  in  the  course  of 
caries  of  the  spine  may  be  found  in  any  part  of  the  cord.  It  is  most 
frequently  met  with  in  diseases  of  the  dorsal  region,  thougli  it  may  occur 
in  the  cervical  and  lumbar  regions.  In  caries  of  the  spine  the  compres- 
sion of  the  cord  is  not  often  the  result  of  pressure  from  the  vertebree,  but 
usually  is  caused  either  by  an  abscess  in  the  vicinity  of  the  diseased  verte- 
brae, or  more  commonly  by  a  thickening  of  the  meninges. 

When  the  lesions  of  the  cord  are  of  any  considerable  extent,  ascend- 
ing and  descending  secondary  degenerations  follow  after  a  time.  If  the 
process  ceases,  it  leaves  a  certain  amount  of  sclerosis  of  the  cord  at  the 
seat  of  the  disease.  This  may  be  very  s'ight,  or  the  cord  may  be  con- 
siderably reduced  in  size  and  yet  transmit  normal  nervous  impulses. 

Symptoms, — The  onset  of  the  disease  is  sometimes  quite  sudden,  but 
more  frequently  it  is  gradual.  The  symptoms  vary  according  to  the  part 
of  the  cord  which  is  affected.  There  is  frequently  pain,  its  location 
depending  upon  the  level  of  the  lesion. 

AVlien  the  lesion  is  in  the  dorsal  or  the  lumbar  region  the  onset  is 
represented  by  numbness  and  weakness  in  the  legs.  This  is  quickly  fol- 
lowed by  a  paralysis  which  jnay  become  complete  in  a  short  time. 

If  the  lesion  is  below  the  level  of  the  sixth  dorsal  vertebra,  the  legs 
alone  are  affected;  if  on  a  level  Avith  this  point,  the  abdominal  muscles 
are  involved.  Sensation  up  to  nearly  the  level  of  the  lesion  may  be 
diminished,  or  even  lost  entii'ely.  In  regions  a])ove  the  lumbar  enlarge- 
ment the  reflex  reactions  are  exaggerated  and  ankle-cleiius  soon  appears. 

When  the  disease  affects  the  cervical  enlargement,  or  any  portion  of 
the  cord  above,  all  the  extremities  are  apt  to  be  paralyzed.  In  severe 
cases  there  will  be  retention  of  urine,  with  subsequent  incontinence. 
The  bowels  are  usually  constipated,  but  incontinence  of  f;tces  is  some- 
times present. 

In  lesions  of  the  lumbar  enlargement  the  knee-jerks  will  be  lost. 
Trophic  changes  in  the  limbs  are  not  marked,  but  the  muscles  are  some- 
what wasted,  and  rigidity  may  develop.  Bed-sores  are  apt  to  form.  The 
reaction  of  degeneration  is  not  present. 


990  PEDIATRICS. 

The  characteristic  feature  of  lesions  in  the  dorsal  region  caused  by 
caries  of  the  spine  is  a  paraplegia. 

Diagnosis. — The  disease  is  to  be  differentiated  from  poliomyeatis  ante- 
rior, in  which  monoplegia  is  more  common  than  paraplegia,  and  in  which 
the  reflexes  are  lost  and  the  reaction  of  degeneration  is  present.  In 
addition  to  this  means  of  making  a  differential  diagnosis,  the  presence  of 
initial  fever  and  prodromata,  the  absence  of  disturbances  of  sensibility,  of 
paralysis  of  the  sphincters,  and  of  a  tendency  to  bed-sores  in  poliomye- 
litis anterior  are  of  great  aid  in  differentiating  it  from  the  results  of  caries 
of  the  spine,  where  rigidity  of  the  limbs,  increased  reflexes,  and  contrac- 
tures are  prominent  symptoms. 

The  differential  diagnosis  from  cerebral  paralysis  is  more  difficult,  as 
the  condition  of  the  limbs  is  similar  in  both.  The  diagnosis  is  made  by 
the  absence  of  all  cerebral  symptoms,  and  by  the  presence  of  such  special 
symptoms  as  rigidity  and  prominence  of  the  vertebrae  in  caries  of  the 
spine. 

Prognosis. — The  prognosis  is  in  general  favorable.  A  certain  number 
of  cases  remain  uncured,  but  nearly  all  recover  under  treatment  if  insti- 
tuted early,  although  the  condition  may  persist  for  months. 

Treatment. — The  treatment  of  these  cases  is,  as  a  rule,  to  be  directed 
to  the  caries,  and  consists  essentially  in  perfect  rest  on  a  rectangular  bed- 
frame.  Massage  and  electricity  are  sometimes  of  assistance  when  applied 
to  the  paralyzed  limbs.  Forcible  correction  of  the  deformity  has  the 
effect  in  many  cases  of  improving  the  paralysis.  When  no  improvement 
occurs  after  several  months,  laminectomy  may  be  considered. 

OBSTETRICAL  PARALYSIS. 
By  obstetrical  paralysis,  or  paralysis  of  the  nevn-horn,  is  meant  that  form 
of  peripheral  paralysis  which  occurs  during  the  delivery,  and  which,  as  a 
^  rule,  affects  the  face  or  one  of  the  extremities.  In  this  sense  it  is  to  be 
separated  from  injuries  to  the  brain  and  spinal  cord  which  are  produced 
during  the  delivery, — in  fact,  from  any  paralysis  of  central  origin  which 
may  occur  in  intra-uterine  life,  either  before  or  at  the  time  of  delivery. 

Etiology  and  Pathological  Anatomy. — The  cause  of  this  form  of  periph- 
eral paralysis  is  most  often  traction  made  upon  the  head  of  the  child 
during  delivery,  while  it  is  in  a  rotated  position,  thus  producing  a  direct 
injury  to  the  nerves,  resulting  either  in  pressure  or  stretching  of  the 
nerves,  and  in  some  cases  in  a  rupture  of  the  two  upper  roots  of  the 
brachial  plexus.  Although  this  form  of  paralysis  has  been  known  in  a 
number  of  cases  to  result  from  pressure  by  the  forceps  during  the 
delivery,  yet  it  has  also  been  met  with  after  an  apparently  normal  delivery, 
where  the  pressure  did  not  seem  to  be  especially  severe  or  prolonged. 

When  the  nerves  of  the  face  are  affected,  the  resulting  lesion  is 
supposed  to  be  from  an  injury  of  the  facial  nerve  ;  and  when  the  arm  is 
affected,  the  lesion  is  supposed  to  be  an  injury  of  the  brachial  plexus  or 


DISEASES   OF   THE  NERVOUS  SYSTEM. 


991 


of  the  nerve-roots  in  the  lower  part  of  the  neck.     As  a  rule,  the  lesion 
is  of  one  arm. 

Symptoms. — This  form  of  paralysis  usually  becomes  apparent  imme- 
diately after  birth,  but  may  be  delayed  for  several  weeks.  When  the  face 
is  affected,  it  is  due,  as  a  rule,  to  an  injury  of  the  seventh  nerve, 
frequently  from  pressure  due  to  forceps,  thus  producing  a  peripheral 
facial  paralysis.  The  peripheral  form  of  facial  paralysis  is  distinguished 
from  the  central  in  that  in  the  former  all  three  branches  of  the  seventh 


Fig.  201. 


Showing  characteristic  position  of  the  arm  in  obstetrical  paralysis  iu  a  girl  of  20  months. 


nerve  are  apt  to  be  affected,  while  in  the  latter  form  only  the  lower  two 
branches  are  involved.  In  the  peripheral  form,  therefore,  the  eye  on  the 
affected  side  cannot  be  closed  entirely,  causing  the  condition  known  as 
lagophthalmia,  and  there  is  inability  to  wrinkle  the  muscles  of  the  fore- 
head on  the  affected  side.  In  facial  paralysis  of  central  origin  the  muscles 
of  the  forehead  are  not  affected,  and  the  ability  to  close  the  eye  is  but 
little  decreased. 

In  the  most  common  form  of  obstetrical  paralysis  of  the  arm,  the 


992  PEDIATRICS. 

so-called  Erb's  type,  there  is  paralysis  of  the  supra-  and  infra-spinatus 
muscles,  the  deltoid,  the  biceps,  the  brachiahs  anticus  and  the  supinator 
longus.  As  a  result  the  arm  is  held  to  the  side  extended  at  the  elbow  and 
in  the  position  of  pronation.  Less  frequently  when  the  lower  trunk  ot 
the  plexus  is  involved  there  may  be  paralysis  of  the  muscles  supplied  by 
the  musculo-spiral,  median  and  ulnar  nerves. 

Diagnosis. — This  form  of  paralysis  is  to  be  diagnosticated  from  cerebral 
paralysis  by  the  absence  of  increased  reflex  irritability,  and  by  the  distri- 
bution of  the  paralysis,  but  principally  by  the  presence  of  the  reaction  of 
degeneration.  In  the  cerebral  form  all  the  muscles  are  affected ;  in  the 
peripheral  form  as  a  rule  groups  of  muscles  are  affected,  but  the  whole 
arm  may  be  paralyzed  in  which  case  one  must  depend  wholly  upon  the 
reaction  of  degeneration  for  the  differential  diagnosis,  It  is  doubtful 
whether  paralyses  of  spinal  origin  occur  in  the  early  days  of  life. 

Cases  of  paralysis  of  the  arm  in  the  new-born  should  also  be  diag- 
nosticated from  surgical  injuries  represented  by  fractures,  dislocations, 
and  separation  of  the  epiphyses. 

Prognosis. — The  prognosis,  so  far  as  the  face  is  concerned,  is  very 
good,  as  the  paralysis  in  these  instances  may  last  but  a  short  time.  We 
must,  however,  be  somewhat  guarded  in  the  opinion  which  we  give  con- 
cerning these  cases,  as  in  some  instances  the  paralysis  does  not  disappear 
and  the  muscles  of  the  face  are  left  irreparably  injured. 

In  regard  to  the  paralysis  of  the  arm,  recovery  depends  upon  the 
amount  of  injury  done  to  the  plexus,  whether  merely  stretched  or  rupt- 
ured. In  the  favorable  cases  marked  improvement  is  evident  in  the  first 
year.  If  no  decided  recovery  of  function  has  taken  place  by  that  time  the 
prognosis  is  very  unfavorable.  Recovery  once  begun  may  proceed  for 
years. 

Treatment. — Electricity  and  massage  should  be  begun  after  two  or 
three  weeks  and  may  have  to  be  continued  for  a  long  period.  Continu- 
ously applied  for  a  number  of  years  they  are  a  very  important  part  of  the 
treatment  of  these  cases,  and  counteract  the  atrophy  of  the  muscles  from 
disuse,  which  must  necessarily  take  place  to  a  greater  or  less  extent. 
Favorable  results  have  been  obtained  from  suturing  the  ruptured  plexus, 
even  after  the  paralysis  has  existed  for  several  years,  but  the  operation  is 
not  without  danger  and  has  been  attended  with  fatal  results. 

The  following  case  is  illustrative  of  the  effects  of  obstetrical  paralysis  : 

A  boy,  two  years  old,  was  healthy  at  birth,  but  the  labor  was  instrumental. 
When  he  was  three  days  old  it  was  found  that  his  left  arm  was  swollen.  He  was  first 
seen  at  the  hospital  when  he  was  seven  weeks  old.  At  that  time  he  was  able  to  move 
his  fingers  and  wrist,  but  held  his  arm  with  the  elbow  straight  to  the  side  and  the 
hand  pronated.  At  the  age  of  two  years  he  was  able  to  make  slight  movements  of 
flexion  of  the  elbow  and  slight  contractions  of  the  deltoid.  Under  the  use  of  elec- 
tricity he  showed  gradual  improvement.  He  could  grasp  objects  fairly  well  with  his 
left  hand,  could  flex  the  elbow  completely,  and  could  raise  his  hand  and  forearm  as  far 


DISEASES   OF   THE   NERVOUS   SYSTEM.  993 

as  the  nipple.     He  could  raise  his  right  arm  with  ease  to  his  head,  but  could  not  raise 
the  left  hand  farther  thun  the  lower  part  of  the  chest. 

NEURALGIA. 

Neuralgia  is  a  functional  affection  of  the  sensory  fibres  of  the  periph- 
eral nerves,  represented  by  pain.  It  is  rare  in  infancy  and  early  child- 
hood. It  may  occur  in  very  different  localities,  and  may  be  repre- 
sented by  intercostal  neuralgia  or  the  various  milder  forms  of  flitting  pains 
in  different  parts  of  the  body.  Neuralgia  of  the  trifacial  nerve  is  the  form 
most  commonly  observed  in  children,  the  most  frequent  cause  of  which 
is  chronic  disease  of  the  nasopharyngeal  space  and  of  tlie  antrum  of  High- 
more,  especially  after  influenza. 

Sciatica  is  a  form  of  neuralgia  virhich  may  occur  in  children,  and  is 
characterized  by  neuralgic  pain  and  tenderness  in  the  course  of  the 
sciatic  nerve,  especially  at  its  point  of  exit  from  the  pelvis. 

In  most  cases  of  neuralgia  temporary  relief  from  the  pain  can  be 
obtained  by  the  use  of  phenacetine.  It  can  be  given  in  doses  of  0.06 
to  0.3  gramme  (1  to  5  grains),  according  to  the  age  of  the  child.  Its 
effects  should  be  guarded  by  giving  brandy  and  water. 

HYDROCEPHALUS. 

By  hydrocephalus  is  meant  an  accumulation  of  serous  fluid  in  the 
cranium.  This  may  occur  either  in  the  subarachnoid  space  [external 
hydrocephalus)  or  in  the  ventricles  {internal  hydrocephalus). 

When  the  accumulation  of  fluid  represents  the  only  pathological 
condition  present  the  term  primary  hydrocephalus  is  used,  while  when  it 
follows  in  the  course  of  other  diseases  it  is  termed  secondary.  Hydro- 
cephalus may  also  be  acute  or  chronic,  congenital  or  acquired. 

Acute  Hydrocephalus.— Etiology.— Acute  hydrocephalus  may  be 
either  external  or  internal,  and  is  usually  a  combination  of  both.  It  is 
generally  sudden  in  its  onset,  and  while  in  some  cases  it  may  be  idio- 
pathic {meningitis  serosa),  in  most  cases  it  is  secondary  to  a  number  of 
conditions,  such  as  cardiac  disease,  pertussis,  rhachitis,  neoplasms,  tumors 
in  the  posterior  fossa,  acute  inflammatory  processes  in  the  brain  and  its 
meninges,  and  acute  febrile  diseases,  such  as  typhoid  and  pneumonia. 

Symptoms.— The  amount  of  fluid  in  these  acute  cases  is,  as  a  rule,  not 
large,  90  to  120  c.c.  (3  or  4  ounces),  and  the  symptoms  are  those 
which  arise  in  meningitis  when  there  is  increased  intracranial  pressure, 
such  as  headache,  vomiting,  unequal  pupils  with  sluggish  reaction,  double 
optic  neuritis,  rarely  convulsions,  and  cerebral  paralyses.  .  In  mild  cases 
recovery  may  take  place  in  a  few  weeks,  but  in  the  more  severe  forms  the 
increased  intra-cranial  pressure  may  prove  fatal. 

Both  the  congenital  and  the  acquired  varieties  of  external  hydrocepha- 
lus are  so  rare  that  they  need  not  be  more  than  mentioned  as  possibly 
occurring  in  certain  congenital  malformations,  in  atrophy  of  the  brain 
{hydrocephalus  in  vacuo),  and  following  cerebral  hemorrhage. 

63 


994  PEDIATRICS. 

The  genera]  shape  and  circumference  of  the  head  in  infancy  and  child- 
hood vary  normally  in  the  individual  to  a  considerable  degree.  On  the 
other  hand,  when  these  variations  in  size  pass  a  certain  limit  or  are  com- 
bined with  certain  nervous  phenomena,  they  have  a  distinct  pathological 
significance. 

Chronic  Internal  Hydrocephalus. — The  chronic  internal  variety  of 
hydrocephalus  consists  of  a  transudation  into  the  cerebral  ventricles.  It 
may  be  congenital  (intra-uterine)  or  acquired  (extra-uterine).  It  may  fol- 
low an  operation  for  spina  bifida  or  be  produced  mechanically  by  internal 
pressure  from  any  cause.  It  may  also  represent  the  termination  of  an 
acute  inflammatory  process. 

The  chronic  form  resembles  so  closely  congenital  internal  hydroceph- 
alus that  we  can  consider  the  two  together.  So  far  as  the  name  of  the 
disease  is  concerned,  the  term  hydrocephalus  should  be  restricted  to  (1) 
congenital  internal  hydrocephalus  and  (2)  chronic  acquired  iiiternal  hydro- 
cephalus. In  other  words,  there  exists  pathologically  a  certain  class  of 
effusions  into  the  ventricles  for  which  no  cause  is  apparent.  When  these 
effusions  reach  a  certain  amount  the  resulting  symptoms  are  quite  typical 
of  what  is  called  hydrocephalus,  and  clinically  the  term  has  therefore  been 
confined  to  cases  of  this  class. 

Pathological  Anatomy. — The  anatomical  appearance  of  the  brain  itself, 
as  a  rule,  corresponds  with  and  may  be  accepted  as  the  result  of  pressure 
by  an  intra-ventricular  fluid.  Fig.  202,  page  995,  represents  the  brain  of  a 
child  who  died  of  congenital  internal  hydrocephalus,  and  well  exemplifies 
the  pathology  of  the  disease. 

The  convolutions  are  flattened  and  the  walls  of  the  ventricles  are 
much  thinned  by  the  intra-ventricular  pressure,  while  the  ventricles 
themselves  are  much  dilated.  In  some  parts  the  cortex  is  less  than  1 
cm.  (f  inch)  in  thickness.  The  amount  of  fluid  in  these  cases  varies 
from  a  few  cubic  centimetres  to'  three  or  four  litres.  The  fluid  'has  a 
specific  gravity  of  about  1004. 

The  earlier  the  hydrocephalic  condition  begins,  the  larger  will  the 
cranium  become.  We  therefore  find  the  very  large  heads,  as,  a  rule,  to  be 
of  the  congenital  variety.  The  head  is  at  times  of  such  a  size  as  to  cause 
difficulty  in  the  delivery,  or  the  fluid  may  collect  very  rapidly  after  birth, 
and  the  head  soon  assumes  the  characteristic  appearance  of  hydrocephalus. 
Figs.  203  and  204  represent  the  hydrocephalic  skull  at  three  years  in 
comparison  with  a  normal  skull  of  the  same  age. 

The  face  in  these  cases  of  hydrocephalus  remains  about  the  same 
size  as  it  would  be  normally,  but  usually  looks  much  smaller  from  the 
disproportionate  size  of  the  head,  which  rests  upon  it  like  a  globe. 

Symptoms. — The  symptoms  of  congenital  internal  hydrocephalus  are 
essentially  those  caused  by  pressure.  We  naturally,  therefore,  find  the 
fontanelles  bulging  and  fluctuating,  and  the  bones  thin  and  forced  out  of 
position.     The  temporal  and  parietal  bones  diverge  as  they  extend  up- 


DISEASES  OF   THE   NERVOUS   SYSTEM.  995 

ward,  while  in  the  normal  skull  they  ascend  almost  perpendicularly 
This  IS  shown  in  Figs.  203  and  204.  If  the  disease  has  existed  for  some 
tmie,  the  upper  wall  of  the  orbit  becomes  flat  and  the  eyeballs  protrude 
The  mtra-cerebral  pressure  often  produces  a  strong  collateral  circulation 
m  the  scalp  and  in  the  forehead,  where  the  veins  appear  like  tortuous 
blue  cords.     Functional  disturbances  are  numerous,  and  vary  in  almost 


Fig.  202. 


Hydrocephalic  brain.    Warren  Museum.    Harvard  University. 


every  case.  As  a  rule,  the  children  are  idiotic,  but  at  times,  even  in 
marked  hydrocephalus,  we  find  the  mental  condition  normal,  even  when 
paralysis  is  present. 

As  the  various  cerebral  centres  become  affected  by  pressure,  symptoms 
arise  corresponding  to  the  parts  of  the  brain  which  are  involved.  Among 
these  symptoms  are  nystagmus  and,  less  frequently,  strabismus.  The 
pupils  at  first  are  usually  moderately  dilated.  Later  they  become  fixed, 
and  sensibility  to  light  is  lost.  The  hearing  lasts  for  a  long  time.  The 
ability  to  walk  is  interfered  with.  Partial  or  general  convulsions,  paral- 
ysis (usually  paraplegic),  and  contractures  may  occur.  Pain  in  the  head 
is  often  complained  of,  but,  as  a  rule,  is  not  so  severe  as  in  meningitis. 
There  is  difficulty  in  keeping  the  head  erect,  owing  to  its  weight.  The 
digestion  is  often  good,  and  the  appetite  .usually  extreme.  The  res- 
piration is  unaffected.  The  pulse  is  usually  not  retarded.  The  tempera- 
ture, as  a  rule,  is  normal.  The  adipose  tissue  is  sometimes  abnormally 
increased. 

Diagnosis. — As  congenital  internal  hydrocephalus  is  almost  invariably 
attended  by  enlargement  of  the  head  and  separation  of  the  sutures,  the 


996  PEDIATRICS. 

diagnosis  is  not  especially  difficult,  and  is  determined  by  comparing  the 
measurements  of  the  head  with  those  of  a  normal  head  of  the  same  age. 
It  must  be  remembered,  however,  that  hydrocephalus  may  exist  with  a 
small  head,  and  that  the  general  shape  and  circumference  of  the  head  in 
infancy  vary  in  the  individual  to  a  considerable  degree.  When,  however, 
these  variations  in  size  pass  a  certain  limit  or  are  combined  with  certain 
nervous  phenomena  they  have  a  distinct  pathological  significance.  In 
addition  to  the  enlargement  of  the  head,  the  symptoms  of  direct  intra- 
cephalic  pressure  make  the  diagnosis  very  simple. 

Prognosis. — These  congenital  cases,  as  a  rule,  die  before  childhooa 
has  been  reached,  but  they  have  been  known  to  live  to  middle  age. 
Death  usually  occurs  from  some  intercurrent  affection.  Complete  re- 
covery is  very  rare.  Moderate  hydrocephalus  is  compatible  with  unusual 
mental  development. 

Treatment. — The  treatment  of  congenital  internal  hydrocephalus  has 
been  varied,  but  without  marked  success.  As  a  certain  number  of  cases 
are  due  to  syphilis,  antisyphilitic  treatment  should  always  be  tried.  When 
the  effusion  is  not  large  and  is  not  increasing,  moderate  pressure  with  a 
rubber  bandage  seems  to  have  a  favorable  result.  When  the  disease  is 
apparently  not  in  an  active  state  and  is  characterized  by  a  very  slight 
increase  of  fluid,  aspiration  through  the  anterior  fontanelle  of  a  small 
quantity  of  fluid  at  a  time  has  been  of  temporary  benefit.  The  point  of 
aspiration  should  be  2  to  3  cm.  (|  inch  to  1 J  inches)  from  the  median 
line,  so  as  to  avoid  puncturing  the  longitudinal  sinus. 

An  operation  for  chronic  hydrocephalus  presents  no  technical  difficul- 
ties. Of  course  only  certain  cases  are  suitable  for  operation.  Moderate 
effusions  should  be  let  alone,  also  those  cases  in  which  a  rudimentary 
development  of  the  brain  is  suspected.  Cases  in  which  an  operation  is 
especially  indicated  are  both  physically  and  mentally  comparatively  well 
developed  up  to  the  time  when  the  enlargement  of  the  cranium  began. 
Such  children  should  show  the  symptoms  of  direct  intra-cranial  pressure. 
They  gradually  become  weak-minded  or  idiotic.  They  do  not  learn  to 
talk,  or  they  quickly  forget  what  they  have  learned.  They  may  also 
become  totally  blind.  The  power  of  walking  is  interfered  with.  Con- 
tractions and  partial  and  general  spasms  are  of  ordinary  occurrence. 
Unless  the  pressure  is  speedily  removed,  atrophy  of  the  brain  results,  and 
if  they  live  they  remain  idiots  for  life.  It  may  be  said  that  the  results 
which  have  followed  the  operative  treatment  of  hydrocephalus  have  not 
been  encouraging. 

Constriction  of  the  scalp  with  adhesive  plaster  is  useless.  If  there  is 
great  excitability  bromide  of  potassium  and  chloral  should  be  given  in 
the  form  of  enemata.  Lumbar  puncture  may  also  be  resorted  to,  and 
is  to  be  preferred  to  the  dangerous  practice  of  puncturing  the  ventricles. 
The  fluid  should  be  withdrawn  guardedly,  the  pulse  and  respiration  being 
watched  with  care. 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


997 


Fig.  205  represents  a  case  of  congenital  hydrocephalus  in  an  infant 
seven  months  old. 

Fig.  205. 


Congenital  internal  hydrocephalus.    Male,  7  months  old. 


Fir;.    206. 


It  had  always  been  nursed.  When  it  was  two  days  old  it  had  convulsions.  Three 
weeks  later  it  had  bronchitis,  and  accompanying  this  disease  a  return  of  the  convul- 
sions, which  occurred  as  often  as  six  or  seven 
times  in  the  day.  They  were  localized  in  the 
left  arm  and  left  leg.  These  convulsions  lasted 
for  three  weeks,  gradually  growing  less  severe. 
There  was  at  this  time  a  certain  amount  of  intes- 
tinal disturbance,  which,  however,  disappeared 
later.  There  was  also  a  history  of  a  purulent 
discharge  from  the  ears  before  the  infant  was 
admitted  to  the  hospital.  It  cried  out  sharply  at 
night.  The  measurements  of  the  head  were  56.5 
cm.  (22f  inches)  in  circumference,  and  36.7  cm. 
(14J  inches)  from  ear  to  ear  over  the  vertex. 
The  anterior  fontanelle  was  bulging.  The  eyes 
were  markedly  divergent  and  protruded  from  their 
orbits. 


Congenital  internal  hydrocephalus. 
Female,  5  years  old. 


Fig.  206   represents  a  child,  five  years 
old,  with  chronic  hydrocephalus. 


She  was  nursed  by  her  mother  for  over  a  year,  and  cut  her  first  tooth  when  she 
was  six  months  old.  She  was  always  well  and  strong,  but  high-tempered.  She  had 
never  had  any  other  disease.  When  she  was  five  months  old  she  fell  from  her  crib 
and  struck  her  head,  but  it  did  not  seem  to  hurt  her  especially.  Her  head  was  always 
noticed  to  be  of  a  peculiar  shape.  When  she  was  eight  months  old  she  fell  out  of  a 
chair  and  was  stunned,  but  was  not  otherwise  hurt.  She  had  convulsions  from  time 
to  time,  but  her  mind  had  always  been  bright.  She  was  unable  to  hold  up  her  head 
until  she  was  three  years  old,  and  had  always  complained  of  more  or  less  frontal  head- 
ache. Her  appetite  had  always  been  excessive,  and  her  taste  for  food  somewhat  pecu- 
liar. She  gradually  grew  stronger  and  was  beginning  to  attempt  to  walk  when  last  seen. 
She  slept  well  and  her  bowels  were  regular.     Her  head  measured  57  cm.  (22^  inches). 

The  following  case  represents  chronic  acquired  internal  hydrocephalus 
in  a  boy  four  years  and  eight  months  old. 

The  child's  parents  were  healthy  ;  his  mother  had  other  healthy  children  and  had 
had  no  miscarriages.  The  child  had  always  been  well,  measles  being  the  only  disease 
which  he  had  ever  had.     At  the  age  of  six  months,  while  in  the  process  of  cutting  a 


998  PEDIATRICS. 

tooth,  he  had  three  convulsions,  from  which  he  recovered  entirely.  His  appetite  had 
always  been  capricious,  but  his  digestion  was  good.  His  bowels  had  always  been  reg- 
ular. He  had  lately  come  from  a  malarial  region,  where  he  had  lived  in  a  rather  damp 
dwelling  for  a  year. 

On  May  6  he  vomited  twelve  or  thirteen  times.  The  vomiting  then  stopped,  but 
returned  later  from  time  to  time.  He  complained  of  pain  in  his  stomach,  had  no  fever, 
and  sometimes  appeared  to  feel  chilly.  His  bowels  were  constipated,  and  in  the  be- 
ginning of  the  attack  his  pulse  was  slow.  He  had  been  subject  to  night-terrors  for 
some  time  previous  to  this  sickness.  The  vomiting  had  lessened  by  May  27,  and  the 
report  of  my  examination  on  that  date  is  as  follows  : 

Pulse  60,  rhythmical  ;  respirations  regular  ;  temperature  normal  ;  has  had  ear- 
ache lately  ;  no  discharge  from  the  ear  since  he  was  an  infant ;  the  examination  of 
the  ear  was  negative  ;  yesterday  morning  he  had  a  general  clonic  convulsion  lasting 
for  some  time  ;  his  tongue  is  slightly  coated  ;  he  lies  in  an  apathetic  state  ;  though 
perfectly  conscious  ;  he  is  losing  in  weight  and  strength,  and  has  lost  his  appetite  ; 
urine  normal.  Nothing  abnormal  is  found  on  examination  of  the  thorax  or  abdomen. 
The  examination  of  the  eyes,  on  June  15,  showed  that  there  was  much  swelling  of  the 
optic  nerve,  increased  prominence  of  the  retinal  vessels,  hemorrhages,  and  neuritis. 
The  child  seemed  much  brighter,  and  played  about.  His  intelligence  was  perfectly 
good ;  he  had  had  no  more  convulsions  and  no  paralysis,  and  seemed  perfectly  well, 
except  that  his  pupils  were  dilated  and  he  was  totally  blind. 

This  child  came  to  see  me  eight  years  later,  when  he  was  twelve  years  old.  He 
had  been  and  was  at  that  time  perfectly  well.  He  was  a  bright,  well-developed,  healthy 
boy.  His  pupils  reacted,  but  he  had  never  recovered  his  sight.  He  weighed  19.8 
kilogrammes  (90  pounds).  His  bowels  were  regular  ;  his  appetite  was  good  ;  his  knee- 
jerks  were  not  increased  ;  his  head  measured  49  cm.  (19|  inches). 

THROMBOSIS  OF  THE  CEREBRAL  SINUSES. 
Etiology. — Thrombosis  of  the  cerebral  sinuses  is  more  frequent  in  in- 
fancy and  early  childhood  than  in  adult  life.  It  is  caused  by  the  forma- 
tion of  an  ante-mortem  clot  in  one  of  the  sinuses  of  the  brain.  As  a 
primary  condition  it  is  exceedingly  rare.  It  is  usually  secondary  to  some 
condition  which  has  produced  an  extreme  reduction  of  the  child's  vitality, 
-such  as  profound  ansemia,  exhausting  diarrhoea,  or  a  collection  of  pus  in 
any  part  of  the  body,  but  especially  about  the  scalp,  as  in  erysipelas.  A 
purulent  otorrhoea  is  perhaps  the  most  common  etiological  factor.  It  is 
not  necessary  here  to  do  more  than  refer  to  the  traumatic  cases  of  this 
disease,  in  which  the  ear  and  the  scalp  are  involved,  as  in  fracture,  or  in 
which  the  thrombosis  is  caused  by  compression,  as  from  a  cerebral  tumor. 
The  pathology  of  the  secondary  cases  includes  the  lesions  of  the  different 
processes  which  have  caused  the  thrombosis.  The  thrombosis  may  take 
place  in  any  of  the  cerebral  sinuses,  and  at  times  may  occur  in  the  course 
of  a  meningitis.  When  the  thrombus  is  formed,  the  venous  branches  be- 
hind the  obstruction  become  distended  mechanically,  and  thus  give  rise  to 
capillary  hemorrhages  and  softening  of  the  floor  of  the  ventricles.  When 
the  thrombosis  has  taken  place  in  the  neighborhood  of  some  inflammatory 
focus,  such  as  a  purulent  otitis  media,  pyaemia  may  result. 

Symptoms. — The  symptoms  which  existed  in  cases  in  which  this  condi- 
tion has  been  found  on  post-mortem  examination  are  not  such  as  to  suf- 


DISEASES    OF  THE   NERVOUS   SYSTEM.  999 

fice  for  making  a  differential  diagnosis  during  life  between  this  and  other 
intra-cranial  conditions,  such  as  occur  in  profound  anaemia.  When,  how- 
ever, convulsions  occur  in  an  atropic  child,  especially  if  there  has  been 
chronic  trouble  in  the  ear,  we  can  suspect  the  presence  of  this  lesion  after 
carefully  differentiating  all  other  causes.  Cases  of  thrombosis  of  the  lateral 
sinus  may  be  suspected  when  there  are  symptoms  of  a  severe  purulent 
affection  following  a  suppurative  otitis,  with  involvement  of  the  mastoid 
cells,  and  when  there  is  cording  and  tenderness  of  the  jugular  vein  and 
oedema  of  the  neck.  In  cases  of  thrombosis  of  the  cavernous  sinus  there 
is  apt  to  be  headache,  drowsiness,  with  exophthalmos,  which  may  become 
extreme,  and  choked  disk. 

Prognosis. — The  prognosis  is  usually  fatal,  except  when  the  throm- 
bosis occurs  in  the  lateral  sinus  and  can  be  relieved  by  operation.  Pitt 
reports  the  recovery  of  a  boy  ten  years  old  who  had  chronic  otorrhoea, 
followed  by  acute  symptoms  of  fever  and  aural  tenderness.  Following 
these  symptoms,  a  week  later,  he  had  a  rigor,  and  optic  neuritis  was 
developed  on  the  right  side.  Exploration  of  the  lateral  sinus  disclosed  a 
clot,  which  was  removed,  and  the  boy  recovered. 

Treatment. — The  treatment  is  wholly  operative. 

The  following  case  of  cerebral  thrombosis  came  under  my  observation 
at  the  infant  hospital : 

An  Infant,  nine  weeks  old,  was  apparently  strong  and  well  up  to  January  16,  when  it 
began  to  lose  in  weight.  By  January  23  it  had  lost  over  200  grammes  (6f  ounces)  with- 
out showing  any  other  symptom  of  disease.  By  Januaiy  27  it  had  lost  480  grammes 
(16  ounces).  Two  days  later  it  was  attacked  with  convulsions  and  died.  The  autopsy 
showed  nothing  abnormal  except  a  capillary  hemorrhage  into  the  ventricles  caused  by 
a  thrombosis  of  the  straight  cerebral  sinus. 

The  pathological  diagnosis  in  this  case  was  that  of  a  sinus-thrombosis  of  undeter- 
mined origin,  a  condition  which  is  exceedingly  rare,  and  instances  of  which,  established 
by  autopsy,  have  seldom  been  reported. 

ATHETOSIS. 

Athetosis  is  a  symptom,  and  not  a  disease,  and  is  represented  by  con- 
tinuous incoordmate  arhythmical  movements  of  the  extremities,  the  face, 
and  the  body.  This  condition  may  be  acquired  or  congenital.  The 
acquired  form  may  follow  cases  of  hemiplegia  or  diplegia,  m  which  event 
it  affects  the  paralyzed  limbs.  Certam  cases  of  acquired  athetosis  occur 
without  any  accompanying  paralysis.  In  congenital  athetosis,  and  in  the 
acquired  form  Avithout  paralysis,  the  symptoms  usually  begin  in  the  first 
year. 

Pathological  Anatomy. — The  pathological  condition  which  exists  in 
cases  of  athetosis  is  supposed  to  be  a  chronic  cerebral  irritation  in  the 
neighborhood  of  the  basal  ganglia  and  in  the  internal  capsule.  The 
condition  as  we  see  it  clinically,  therefore,  is  wholly  a  symptom  of  some 
organic  lesion  of  the  brain. 

Diagnosis. — The  diagnosis  of  acquired  athetosis  is  made  by  the  character 


1000  PEDIATRICS. 

of  the   movements.     These  are  contmuous,  and  are  distinguished  from 
those  of  chorea  by  being  vermicular  and  less  spasmodic. 

The  diagnosis  in  cases  of  congenital  athetosis  is  not  difficult,  as  in  no 
other  disease  does  an  infant  present  at  birth  these  peculiar  movements 
and  this  grotesque  form  of  flexion  and  hyper-extension  of  the  fingers  and 
toes.  Attempted  movements  are  associated  with  incoordination.  The 
disease  called  congenital  chorea,  in  which  involuntary  arrhythmical  move- 
ments exist,  is  distinguished  from  athetosis  by  the  character  of  the 
movements,  which  in  the  former  resemble  those  of  ordinary  chorea. 

Fig.  207. 


L^ 


1 


Congenital  athetosis.    Female,  2  rears  old. 

Prognosis. — The  prognosis  of  athetosis  in  regard  to  recover)^  is  un- 
favorable. So  far  as  the  general  health  is  concerned,  the  individual  may 
develop  fairly  well  and  may  live  for  years. 

Treatment. — There  is  no  known  treatment  which  has  proved  to  be  of 
benefit  in  children.  As  they  grow  older  the  training  of  the  affected  limbs 
may  be  undertaken,  but,  as  a  rule,  the  results  are  unsatisfactor5\  Massage 
and  electricity  have  proved  to  be  of  no  value. 

Fig.  207  represents  congenital  athetosis  in  a  girl  two  years  old.  She  never  had  had 
any  acute  disease.  She  was  born  after  a  normal  labor,  and  had  received  no  subsequent 
injury.  She  had  never  talked  nor  shown  much  interest  in  her  surroundings,  nor  had 
she  been  able  to  sit  up  or  hold  up  her  head  without  support.  The  bowels  had  always 
been  regular  and  the  appetite  good.     She  was  well  developed  and  w^ell  nourished. 

The  disease  was  characterized  by  the  continual  incoordinate  arrhythmical  move- 
ments of  the  head,  trunk,  and  extremities  ;  these  movements  were  often  quite  rapid. 
There  were  constant  flexion  and  extension  of  the  hands  and  fingers,  the  fingers  at  times 
being  bent  backward  and  assuming  most  grotesque  positions.  This  phenomenon  was 
also  seen  in  the  toes.  The  expression  of  the  face  was  not  that  of  ordinary  intelligence. 
The  reflexes,  on  account  of  the  resistance  of  the  child  to  examination,  could  not  be 
determined.  She  was  usually  irritable,  but  occasionally  smiled  slightly,  and  took 
some  slight  notice  of  those  who  were  near  her. 


DISEASES   OF   THE   NERVOUS  •  SYSTEM.  IQOl 

INTRA-ORANIAL  TUMORS. 
Etiology.— In  infancy  and  early  childhood  tumors  of  many  varieties 
may  occur  in  the  brain  and  its  meninges.  The  most  common  form  of 
intra-cranial  tumor  is  tubercular.  The  next  in  frequency  are  glioma, 
sarcoma,  and  glio-sarcoma.  The  other  varieties,  such  as  carcinoma, 
lipoma,  myxoma,  and  teratoma  are  very  rare  ;  syphilitic  gumma,  which 


Fig.  208 


yarcoma  of  the  brain  in  a  girl  of  23^  years. 

is  so  frequent  in  adults,  is  exceedingly  rare  in  infancy  and  early  child- 
hood. The  parasitic  cysts  in  the  brain  which  occur  quite  frequently  in 
individuals  in  other  parts  of  the  world,  especially  in  Germany,  are  seldom 
met  with  in  this  country. 

These  tumors  may  arise  either  in  intra-  or  extra-uterine  life.     Of  these 
the  tubercular  is  the  most  common. 


Fig.  208. 


Sarcoma  of  the  brain  in  a  girl  of  2}^  years. 

Pathological  Anatomy. — The  tubercular  tumors  of  the  brain  or  its 
meninges  are,  as  a  rule,  secondary  to  a  tubercular  growth  in  some  other 
part  of  the  body,  or  to  tubercular  disease  of  some  part  of  the  skull,  such 
as  the  orbit  or  ear.  These  tubercular  tumors  may  be  single  or  multiple, 
the  latter  being  the  more  common  variety.    They  may  be  found  in  any 


1002 


t'EDIATRICS. 


Fig.  209. 


part  of  the  brain  or  its  meninges,  and  occur  with  especial  frequency  in  the 
cerebellum.  They  may  vary  in  size  from  a  small  collection  of  miliary 
tubercles  to  large  masses.  When  one  or  more  cheesy  masses  of  a  tuber- 
cular nature  are  found  in  different  parts  of  the  brain,  the  condition  is 
called  solitary  tubercle.  The  gliomata  grow  most  frequently  in  the 
white  substance  of  the  brain,  but  sometimes  develop  in  the  gray  matter. 
According  to  Starr,  they  grow^  less  rapidly  than  sarcomata,  and  never 
involve  the  membranes.  They  are  usually  primary,  but  may  develop 
secondary  to  glioma  of  the  retina.  The  sarcomata  are  both  of  the 
round-celled  and  of  the  spindle-celled  variety.     Although  not  quite  so 

frequently  found  as  the  gliomata,  they  are 
more  frequent  than  the  glio-sarcomata  or 
myxomata.  They  are  usually  round  in 
shape,  develop  both  in  the  nervous  tissue 
and  in  the  cerebral  membranes,  and  i:i 
both  the  white  and  gray  matter  of  the 
cerebrum  and  cerebellum.  The  other 
varieties  of  tumor  of  the  brain  are  so  rare 
that  they  need  not  be  considered  here. 

Intra-cranial  aneurisms   are    rare    in 
childhood  and  are  never  very  lai^e.   They 
are  found  in  the  larger  arteries  of  the  base 
of  the  brain  and  in  the  Sylvian  arteries. 
1  ■'.'-"■■ 'jir  T  Symptoms.  —  The    general    symptoms 

R*"     /^  vary  very  nmch  in  accordance  with  the 

sarcomaoftheskuuiiiaboy  of  2years.  sizc  and  Vascularity  of  the  tumor,  and  ac- 
cording as  it  is  growing  or  has  become 
stationary.  In  the  former  case  the  symptoms  are  often  apt  to  be  more 
severe  than  later,  when,  the  tumor  having  become  stationary,  the  brain- 
tissue  adapts  itself  to  the  new  conditions  produced  by  the  morbid 
growth.  Intra-cranial  tumors  in  infants  and  in  young  children  are  often 
latent,  present  no  symptoms,  and  are  sometimes  discovered  only  after 
death.  A  certain  number  of  cases,  on  the  other  hand,  present  only 
general  symptoms,  such  as  headache,  cerebral  vomiting,  attacks  of 
vertigo,  staggering,  convulsions,  and  optic  neuritis,  which  cause  us  to 
suspect  intra-cranial  disease,  but  give  no  definite  idea  of  its  location. 
Again,  these  tumors  may  produce  localizing  symptoms  in  addition  to  the 
general  ones.  These  are  represented  by  paralyses  of  different  kinds, 
irritative  symptoms,  leading  to  attacks  of  Jacksonian  epilepsy,  anomalies 
of  sensation,  and  affections  of  the  special  senses.  These  later  symptoms 
arise  according  to  the  site  of  the  tumor  and  the  parts  of  the  brain  which 
are  affected  by  it,  and  by  means  of  them  we  can  more  or  less  approx- 
imately judge  of  its  situation,  and  rapidity  of  growth. 

Paralyses  of  the  extremities  are  caused  by  an  affection  of  the  motor 
cortex,  the  internal  capsule,   or  any  portion  of  the  motor  tract  on  the 


DISEASES   OF  THE  NERVOUS   SYSTEM.  1003 

opposite  side  of  the  brain,  above  the  crossing  of  the  pyramids.  Stagger- 
ing althougli  a  general  symptom  of  intra-cranial  pressure  may  be  of  a 
characteristic  type  in  cerebellum  disease,  and  in  these  cases  the  tendency 
is  to  stagger  to  one  side.  It  is  also  an  important  fact  that  in  tumor 
of  the  cerebellum  the  optic  neuritis  appears  early  and  the  symptoms 
of  intra-cranial  pressure  develop  rapidly  owing  to  pressure  on  the 
aqueduct  of  Sylvius,  giA'ing  rise  to  internal  hydrocephalus.  The  in- 
volvement of  the  intra-cranial  nerves  suggests  a  tumor  of  the  base  of 
the  bram  or  pressure  on  these  nerves  at  some  point,  and  more 
rarely  an  affection  of  their  nuclei.  The  tendon  reflexes  are  apt  to 
be  exaggerated,  but  in  cerebellar  tumor  are  frequently  absent.  The 
child  in  cerebellar  disease  has  a  subjective  sense  of  falhng  or  turning 
back,  and  grasps  for  support  or  sinks  into  a  chair  or  to  the  floor. 
This  form  of  ataxia  is  to  be  distinguished  from  that  which  is  found  in 
spinal  disease,  where  it  is  due  to  an  inability  to  co-ordinate  properly  the 
muscles  of  the  lower  extremities.  This  latter  form  of  ataxia  is  much  more 
regular  than  the  former,  each  step  being  insecure  and  unsteady,  but  ^^'ith- 
out  the  violent  and  sudden  reeling,  after  two  or  three  steady  steps,  which 
occurs  in  the  cerebellar  fomi.  In  young  infants  a  tumor  may  cause  a  pro- 
tuJDerance  of  some  part  of  the  skull  by  pushing  one  of  the  bones  outward. 

Diagnosis. — The  diagnosis  of  tumors  of  the  braui  must  in  the  great 
majority  of  cases  be  made  by  elimination.  The  variety  of  tumor  can  be 
determmed  most  readily  by  considering  the  history  of  the  case,  as  to 
whether  it  is  tubercular,  syphilitic,  or  otherwise.  The  diagnosis  of  a 
tumor  can  often  be  made  by  the  slow  and  gradual  development  of  the 
disease.  When  severe  headache  and  vomiting  exist,  followed  by  paraly- 
sis, either  monoplegic  or  hemiplegic,  especially  if  this  paralysis  develops 
slowly,  we  should  suspect  the  presenile  of  some  form  of  mtra-cranial 
growih.  This  suspicion  is  much  strengthened  by  the  presence  of  optic 
neuritis  or  optic  atrophy.  The  presence  of  localized  convulsions  in  such 
cases  tends  to  confirm  the  diagnosis,  while  if  marked  ataxia  exists  we  are 
justified  in  suspecting  cerebellar  disease.  A  normal  or  only  slightly  ele- 
vated temperature  with  these  symptoms  also  points  to  a  diagnosis  of  a 
cerebral  tumor.  The  reader  is  referred  to  Starr's  "  Surgery  of  the  Brain" 
for  a  more  extended  consideration  of  the  signs  and  symptoms  by  which 
the  localization  of  the  tumor  is  determined. 

Prognosis. — The  prognosis  of  tumors  in  early  life  is  very  unfavorable, 
no  matter  what  the  variety  may  be.  There  may  be  a  remission  of  symp- 
toms, but  this  should  not  mislead  one  into  giving  a  favorable  prognosis. 
Although  the  patient  may  for  a  long  time  remain  wholly  unaffected  by  the 
morbid  growth,  he  eventually,  except  in  rare  cases,  succumbs  to  the  disease. 

Treatment. — Surgical  interference  in  children,  as  in  adults,  proves,  on 
the  whole,  to  be  the  most  valuable  means  at  our  command  for  lengthening 
life  in  cases  of  cerebral  tumors,' but  the  results  have  not  been  what  was 
hoped  for  when  cranial  surgery  came  first  into  prominence.     There  is  no 


1004  PEDIATRICS. 

other  treatment  which  is  of  any  especial  benefit  in  either  retarding  the 
growth  or  curing  this  class  of  cases.  Although  operation  rarely  results  in 
a  cure,  it  is  often  advisable  as  a  palliative  measure  to  relieve  the  intense 
headache  and  prevent  rapid  loss  of  sight.  Where  the  exceedingly  rare 
form  of  syphilitic  gumma  exists,  iodide  of  potassium  may  be  of  much 
value,  and  is  indicated  as  in  adults. 

The  following  case  was  one  of  solitary  tubercules  of  the  brain  : 

An  infant,  thirteen  months  old,  had  never  had  any  especial  disease,  and  entered 
the  hospital  Aveak  and  emaciated.  Its  mind  was  clear.  Its  pulse  was  weak  but  regular, 
and  neither  slow  nor  rapid  for  its  age.  Its  temperature  was  at  times  somewhat  raised, 
varying  from  37.2°  to  38.4°  C.  (99°  to  101°  F.).  There  were  no  convulsions,  and  no 
paralysis  or  contractures,  but  merely  progressive  loss  in  weight,  and  finally  death. 

An  examination  of  the  brain  showed  miliary  tubercles  of  the  pia  mater  at  the  base 
of  the  brain  without  acute  inflammation,  which  accounted  for  the  lack  of  acute  cerebral 
symptoms.  Of  especial  interest,  however,  in  the  case  were  some  patches  of  solitary 
tubercles,  1.2  cm.  (h  inch)  in  diameter,  in  the  left  temporal  and  occipital  lobes  and  in 
the  right  frontal  lobe  of  the  cerebrum,  and  also  in  the  lower  left  cerebellum.  There 
were  also  caseous  tubercles  of  the  post-bronchial  lymph-nodes,  tubercles  of  the  lungs 
with  a  slight  amount  of  broncho-pneumonia,  miliary  tubercles  of  the  pleura,  liver,  and 
spleen,  and  caseous  tubercles  of  the  mesenteric  lymph-nodes. 

CEREBRAL  SYPHILIS. 

Intra-cranial  syphilis  may  be  either  congenital  or  acquired.  The  intra- 
cranial lesions  are  essentially  the  same  in  both  forms. 

Pathological  Anatomy. — Intra-cranial  syphilis  may  be  divided  patho- 
logically into  three  forms :  (1)  diffuse  inflammation  of  the  meninges  or 
their  neighboring  tissues,  (2)  localized  growths  or  tumors  (gummata),  and 
(3)  syphilitic  endarteritis.  In  the  latter  case  there  may  be  local  dilatation 
or  local  occlusion  of  the  blood-vessels.  These  conditions  are  apt  to 
occur  simultaneously.  When  the  dilatation  reaches  an  advanced  stage  a 
thinning  of  the  arterial  walls  results,  which  may  lead  to  rupture  of  the 
~blood-vessels  or  to  hemorrhage..  More  common  than  the  hemorrhage, 
hoAvever,  is  the  occlusion  of  the  blood-vessels,  which  cuts  off  the  blood- 
supply  and  acts  in  the  same  way  as  in  the  other  cases  of  thrombosis  of  the 
arteries,  causing  more  or  less  softening  and  disintegration  of  the  cerebral 
tissues  supplied  by  them.  The  arteries  of  the  base  of  the  brain  are  the 
ones  that  are  most  frequently  affected,  and  there  are  secondary  lesions  of 
the  parts  of  the  brain  supplied  by  them. 

Symptoms. — The  symptoms  dependent  on  these  lesions  vary  in  accord- 
ance with  the  pathological  condition. 

In  syphilitic  meningitis  the  principal  symptoms  are  severe  headache  in 
various  parts  of  the  head,  more  or  less  constant,  lasting  for  many  days  or 
even  wrecks,  and  frequently  accompanied  after  a  time  by  paralysis  of 
some  of  the  intra-cranial  nerves,  especially  of  the  third  or  of  the  seventh. 
As  in  other  cases  of  meningitis,  the  optic  nerves  may  also  be  affected, 
and  the  child  shows  the  general  symptoms  of  a  severe  intra-cranial  affec- 
tion, such  as  vomiting,  dulness,  headache,  and  localized  paralyses. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  1005 

The  localized  tumors  or  gummata  present  essentially  the  same  symp- 
toms as  other  forms  of  tumors  of  the  brain. 

The  symptoms  produced  by  syphilitic  endarteritis  vary  according  to 
the  areas  of  the  brain  affected,  but  the  most  common  ones  are  the 
various  forms  of  paralysis  of  the  extremities  and  sensory  disturbances. 

Diagnosis. — In  regard  to  the  diagnosis  of  cerebral  syphilis  in  children, 
the  symptoms  differ  greatly  in  different  cases.  The  most  characteristic 
group  of  symptoms,  and  one  which  is  exceedingly  suggestive  of  intra- 
cranial syphilis,  includes  attacks  of  organic  paralysis,  central  in  origin, 
occurring  at  intervals  of  days  or  months  without  kno^^^l  cause,  and  with- 
out marked  symptoms  of  either  tumor  or  tuberculosis 

The  diagnosis  of  syphilitic  meningitis  may  be  made  from  the  occur- 
rence of  severe  headaches,  followed  by  paralysis  of  one  or  more  of  the 
motor  cranial  nerves,  and  occurring  without  marked  rise  of  temperature. 

Gummata  present  no  especial  symptoms  from  other  intra-cranial 
tumors.  The  presence  of  syphilitic  lesions  elsewhere  or  a  history  of 
sj^phiHs  in  the  parents  is  our  principal  ground  for  making  the  diagnosis. 

Syphilitic  endarteritis  may  be  suspected  when  an  acute  affection  in  the 
neighborhood  of  the  pons  or  medulla  not  produced  by  traumatism  occurs 
in  a  syphilitic  subject,  or  when  acute  symptoms  suggestive  of  hemorrhage 
or  embolism  are  present,  and  when  no  other  probable  cause  can  be 
shown,  such  as  cardiac  or  renal  disease. 

Prognosis  and  Treatment. — The  results  of  antisyphilitic  treatment  in 
these  cases  are  sometimes  striking.  The  treatment  should  be  pushed 
rapidly  to  the  limit  of  tolerance. 

MENINGITIS. 

Although  inflammation  of  the  meninges  may  occur  secondarily  to 
disease  of  the  brain  itself,  and  may  affect  either  the  dura  mater  or  the 
pia  mater,  yet  clinically  by  far  the  most  common  condition  met  with 
in  early  life  is  a  leptomeningitis^  (inflammation  of  the  pia),  forming  itself 
the  most  important  part  of  the  morbid  process.  Pachymeningitis,  (inflam- 
mation of  the  dura),  is  in  early  life  so  rare,  except  from  traumatism  or  as 
a  lesion  of  some  specific  disease  such  as  syphilis,  that  it  need  simply  be 
mentioned  as  of  possible  occurrence. 

Meningitis  may  be  caused  by  various  specific  organisms,  such  as  the 
tubercle  bacillus,  the  diplococcus  intracellularis,  the  pneumococcus,  the 
typhoid  bacillus,  the  influenza  bacillus,  and  others,  or  it  may  be  secondary 
to  other  diseases  or  lesions  of  traumatic  origin.  The  symptoms  in  all  are 
very  similar  and  depend  largely  on  the  intensity  of  the  inflammation  and 
on  the  parts  of  the  brain  affected.  These  secondary  forms  are  grouped 
under  the  head  of  simple  acute  meningitis.  Tubercular  meningitis  has 
been  described  on  page  401  and  cerebro-spinal  meningitis  on  page  423. 

Simple  Acute  Meningitis. — Etiology. — An  acute  meningitis  may 
arise  in  the  course  of  a  number  of  infectious  diseases,  such  as  erysipelas 


1006  PEDIATRICS. 

or  ulcerative  endocarditis;  also  after  insolation  and  Injuries  to  the  head. 
It  may  attack  robust  as  Avell  as  debilitated  children,  and  may  occur  at  all 
ages.  It  is  rare  in  the  first  year  of  life  and  is  most  common  in  the  middle 
period  of  childhood.  It  is  especially  liable  to  arise  from  an  extension  of 
the  inflammation  from  disease  of  the  ear,  and  this  in  young  subjects  may 
take  place  through  the  unclosed  petrosquamosal  suture. 

The  cases  of  idiopathic  meningitis  which  have  been  reported,  which 
are  not  due  to  the  specific  organisms  already  described,  are  probably  due 
to  some  slight  traumatism  which  has  passed  unnoticed. 

Pathological  Anatomy. — The  pathology  of  simple  acute  meningitis  is 
practically,  in  infants  and  young  children,  an  inflammation  of  the  pia 
mater,  but  there  is  also  usuahy  a  mild  grade  of  inflammation  of  the  dura 
and  of  the  gray  matter  of  the  brain.  It  may  be  acute  or  chronic,  and  non- 
purulent in  character.  The  arachnoid  may  appear  somewhat  opaque  and 
the  cerebral  substance  oedematous.  There  is  an  increase  in  the  cerebro- 
spinal fluid  and  the  ventricles  may  be  so  distended  as  to  correspond  to  an 
acute  hydrocephalus.  The  pia  of  the  convexity  is  most  frequently 
affected,  while  that  of  the  base  may  be  entirely  free,  with  possibly  a 
slightly  increased  exudation  of  lymph  in  the  interpeduncular  space. 

There  is  usually  an  extravasation  of  white  blood-corpuscles  near  the 
blood-vessels,  which  are  found  on  microscopic  examination  to  be  slightly 
engorged.  When  the  meningitis  has  lasted  for  a  time,  the  pia,  because 
of  the  agglutination  which  has  taken  place,  cannot  be  removed  without 
injuring  the  gray  matter.  In  any  case  of  acute  meningitis  the  inflam- 
mation is  apt  to  extend  downward  and  to  involve  the  pia  mater  of  the 
cord. 

In  the  chronic  form  the  pia  mater  at  the  base  of  the  brain  alone  may 
be  inflamed  (basilar  meningitis),  or  the  lesions  may  be  found  distributed  in 
small  or  large  areas  over  the  convexity.  In  these  cases  the  pia  mater  is 
ihick  and  opaque,  and  there  is  a  production  of  pus,  fibrin,  and  serum,  with 
a  formation  of  new  connective  tissue.  The  relative  quantity  of  these  in- 
flammatory products  varies,  and  sometimes  results  in  firm  and  extensive 
adhesions  between  the  dura  and  the  pia  mater.  Other  conditions  which 
represent  the  results  of  chronic  inflammation  may  also  be  present,  but 
need  hardly  be  referred  to  here,  further  than  to  say  that  the  ventricles  of 
the  brain  may  in  this  chronic  form  contain  an  increased  amount  of  serum 
and  may  be  dilated.  The  ependyma  also  may  be  thickened  and  rough- 
ened. 

Symptoms. — When  acute  simple  meningitis  is  secondary  to  injuries  or 
to  other  diseases,  the  characteristic  symptoms  may,  of  course,  be  compli- 
cated and  even  obscured  by  those  of  the  primary  cause.  The  symptoms, 
however,  are  very  similar  to  all  the  other  forms  of  meningitis  which  have 
been  described  under  spe'cific  infectious  diseases  except  that  they  may  cor- 
respond to  an  inflammatory  condition  of  the  convexity  rather  than  to  that 
of  the  base.     The  course  is  often  short,  sometimes  not  more  than  seven 


DISEASES    OF    THE    NERVOUS   SYSTEM.  1007 

or  eight  days.  The  disease  may,  however,  prove  fatal  in  forty-eight 
hours ;  on  the  other  liand,  it  may  last  a  number  of  weeks.  When  the 
convexity  is  chiefly  affected,  the  onset  is  characterized  by  intense  head- 
ache, vertigo,  vomiting  (usually  of  a  cerebral  type),  and  a  high  tempera- 
ture, 40°  to  41.1°  C.  (104°  to  106°  F.).  The  respirations  are  rapid,. 
30  to  50,  and  comparatively  regular.  The  pulse  in  the  early  stages  is 
rapid,  150  to  170,  but  is  usually  regular;  later  it  becomes  irregular  and 
slow.  Convulsions  occur  early  in  the  attack.  Irritability,  listlessness, 
apathy,  and  drowsiness  subsequently  develop.  The  pupils  are  contracted 
at  first,  but  later  become  dilated  ;  delirium  appears  ;  rigidity  of  the  neck 
is  present,  and  in  some  cases  a  marked  spastic  condition  of  the  lower 
extremities.  The  deep  reflexes  are  usually  uicreased ;  the  abdomen  is 
retracted,  and  the  bowels  are  constipated. 

All  these  symptoms  develop  rapidly  in  a  few  days,  and  then  are  in- 
tensified as  the  disease  progresses.  Blindness  from  optic  neuritis  and  ocu- 
lar paralyses  m  the  form  of  strabismus  and  ptosis  may  appear.  A  tache 
cerebrale  is  apt  to  be  found,  but  is  not  diagnostic.  A  monoplegic  or 
hemiplegic  paralysis  having  all  the  symptoms  of  a  cerebral  paralysis  may 
develop.  In  favorable  cases  the  symptoms  lessen  in  severity,  and  the 
rigidity,  blindness,  and  paralysis  gradually  disappear  as  the  child  comes 
out  of  its  coma.  In  fatal  cases  the  symptoms  grow  still  more  severe  ; 
the  rigidity  and  retraction  of  the  neck  increase ;  opisthotonos  may  occur, 
and  the  respiration  assumes  a  markedly  Cheyne-Stokes  type  until  it 
ceases  at  death.  Photophobia,  contracted  pupils,  and  delirium  are 
present. 

DuGxosis. — Great  caution  should  be  used  in  differentiatmg  a  smiple 
acute  meningitis  from  the  cerebral  symptoms  accompanying  so  many  acute 
infectious  diseases,  for  the  symptoms  are  often  ver}^  similar.  Other  dis- 
eases should  therefore  first  be  excluded.  The  nature  of  the  infection  is 
definitely  determined  by  lumbar  puncture  and  by  bacteriological  and  his- 
tological examination  of  the  fluid  withdrawn. 

The  form  of  meningitis  wdiich  is  to  be  especially  differentiated  from 
simple  meningitis  is  the  tubercular,  in  which  the  symptoms  correspond 
more  to  lesions  of  the  base  of  the  brain  as  described  on  page  401. 

Prognosis. — The  prognosis  is  very  unfavorable.  It  is  possible,  how- 
ever, for  the  child  to  recover  completely.  Perhaps  only  a  changed  mental 
condition  will  remain,  boys  appearing  effeminate  or  more  easily  excited 
than  would  be  considered  normal.  Some  of  the  more  acute  forms  affect 
also  the  brain,  and  we  find  their  results  in  idiocy  and  contractures.  Epi- 
lepsy from  irritation  caused  by  adherent  membranes  may  subsequently 

develop. 

Treatment. — The  treatment  of  simple  acute  meningitis  varies  with  that 
of  the  disease  or  condition  to  whiuh  it  is  secondary.  The  child  should 
be  kept  in  a  cool,  dark  room  and  protected  from  noise.  In  the  treatment 
of  meningitis,  whether  primary  or  secondary,  the  indications  are  to  re- 


1008  PEDIATRICS. 

duce  the  temperature  of  the  body  and  to  support  the  general  strength 
until  the  disease  has  run  its  course.  The  former  is  accomplished  best  by 
sponging  the  entire  body  every  three  or  four  hours  with  water  at  a  tem- 
perature of  from  15.5°  to  22.2°  C.  (60°  to  70°  F.),  and  by  the  appli- 
cation of  cold  to  the  head  preferably  by  Leiter's  coil.  The  strength 
should  be  supported  by  the  administration  of  milk,  and,  when  necessary, 
of  stimulants. 

The  bowels  should  be  freely  moved  with  some  purgative  such  as  calo- 
mel. Bromide  of  soda  in  doses  varying  from  0.3  gramme  (5  grains)  to 
0.9  gramme  (15  grains)  should  be  given  according  to  the  age  of  the  child, 
and  every  four  to  six  hours  according  to  the  severity  of  the  symptoms. 

In  cases  of  recovery  the  greatest  care  should  be  taken  to  keep  the 
child  free  from  excitement  for  many  months,  and  to  insure  an  absolutely 
restful  life  with  freedom  from  physical  and  mental  fatigue.  ]\Iassage  and 
electricity  should  be  used  when  there  are  paralyses  and  contractions. 

ACUTE  ENOEPHATiTTIS. 

Although  this  disease  is  frequently  associated  with  leptomenmgitis,  and 
may  occur  by  simple  extension  m  meningitis  due  to  traumatism  or  to 
acute  or  chronic  intoxication,  it  may  also  occur,  independently  of  menin- 
geal lesions,  and  usually  before  puberty,  and  freciuently  is  a  complication 
.of  infectious  diseases,  especially  of  scarlet  fever,  measles,  and  mumps. 

Symptoms. — For  a  few  days  headache,  dizziness,  irritability,  or  depres- 
sion are  noticed.  The  drowsiness  increases  to  coma,  but  the  loss  of  con- 
sciousness need  not  be  complete,  and  remissions  may  be  distinct  in  the 
first  week  of  the  disease.  The  pupillary  reflexes  are  normal  or  sluggish  ; 
the  deep  and  superficial  reflexes  are  not  altered.  Convulsions,  rigidity  of 
the  neck  and  opisthotonos,  monoplegia,  or  hemiplegia  develop  early,  and 
aphasia  may  or  may  not  be  present,  the  symptoms  depending  largely 
upon  the  area  of  the  brain  aff'ected.  Ocular  and  cranial  paralyses  occur 
and  simulate  basilar  meningitis,  excepting  that  the  loss  of  consciousness  is 
not  complete.  The  respiration  may  become  irregular  and  the  pulse  slow, 
rapid,  or  irregular.  The  disease  may  last  two  or  three  weeks  and  then 
prove  fatal,  or  there  may  be  prolonged  remissions  and  complete  recovery. 

Striimpell,  Furbringer,  and  others  have  endeavored  to  establish  a  form 
of  acute  hemorrhagic  encephalitis  developing  commonly  after  some  acute 
infectious  disease,  especiaUy  influenza,  and  the  pathology  is  supposed  to 
consist  in  small  and  strictly  circumscribed  inflammatory  areas  which  may 
be  developed  in  symmetrical  parts  of  the  brain.  Lumbar  puncture  may 
yield  a  fluid  under  considerable  pressure,  which  may  contain  organisms 
with  a  few  cellular  elements  but  no  pus. 

Progxosis. — The  prognosis  is  bad  according  to  the  intensity  of  the 
symptoms  and  the  degree  of  septicaemia  present. 

Treatmext. — The  treatment  should  be  such  as  has  been  described  for 
simple  acute  meningitis. 


DISEASES  OF  THE   NERVOUS   SYSTEM.  1009 

BULBAR  PARALYSES. 

Diseases  of  the  pons  and  medulla  are  very  rare,  but  may  occur  in 
children  with  the  same  symptoms  as  in  adults.  They  need  not  be  more 
than  mentioned. 

Polio-encephalitis,  superior  and  inferior,  and  the  acute  and  pseudo-bulbar 
paralyses  occur  so  rarely  in  early  life  that  they  hardly  have  a  place  in  the 
nervous  diseases  of  childhood. 

MULTIPLE  NEURITIS. 

Neuritis  is  an  inflammation  of  the  peripheral  nerves.  It  is  accom- 
panied- by  pain  and  tenderness  in  the  affected  regions,  and  in  the  more 
severe  cases  by  paralysis  and  atrophy.  Neuritis  of  a  single  nerve-trunk  or 
of  its  branches  may  be  caused  by  traumatism,  cold,  or  pressure,  or  may 
occur  in  the  course  of  various  diseases.  In  certain  constitutional  con- 
ditions a  number  of  nerves  in  different  parts  of  the  body  are  affected, 
constituting  the  disease  called  muUipjle  neuritis. 

Etiology. — Multiple  neuritis  usually  occurs  in  the  course  of  or  sub- 
sequent to  one  of  the  infectious  diseases.  Of  these  diphtheria  is  the 
most  common,  but  it  is  said  to  follow  scarlet  fever  and  measles.  A 
mild  form  sometimes  occurs  after  typhoid  fever.  At  times  multiple  neu- 
ritis is  produced  by  drugs,  such  as  lead,  arsenic,  or  alcohol.  This  form 
is  not  a  common  disease  among  children.  The  epidemic  form  of  the 
disease,  known  by  the  terms  kakke  and  beri-beri,  is  quite  rare  in  this 
country. 

Pathological  Anatomy. — The  pathological  condition  in  aiultiple  neuritis 
is  an  interstitial  inflammation  or  parenchymatous  degeneration.  A  few 
nerves  may  be  affected,  or  the  distribution  may  be  general.  The  cranial 
nerves  are  rarely  affected. 

Symptoms. — The  onset  of  the  disease  may  be  acute  or  subacute,  but  in 
most  cases  is  gradual.  It  may  at  the  beginning  present  severe  symp- 
toms, such  as  extreme  pain,  tenderness  over  the  nerve-trunks,  and  fever 
with  an  accompanying  paralysis.  On  the  other  hand,  the  pain  in  the 
beginning  may  be  very  slight,  and  the  first  symptoms  noticed  may  be  a 
gradually  increasing  weakness  of  the  limbs,  while  the  tenderness  may  be 
found  only  when  especially  sought  for.  There  may  be  hypertesthesia, 
ansesthesia,  numbness,  and  loss  of  muscular  power.  Both  the  sensory  and 
motor  nerves  are  affected  and  the  condition  is  symmetrical.  After  the 
acute  symptoms  have  passed  away  the  faradic  irritability  is  diminished :  the 
action  of  the  nerves  to  the  galvanic  current  is  diminished,  and  the  reaction 
of  degeneration  develops.  When  the  extensors  of  the  leg  are  involved 
there  is  foot-drop,  and  when  those  of  the  forearm  are  affected  there  is 
wrist-drop.  Rarely  all  the  muscles  of  the  extremities  may  be  paralyzed, 
and  the  child  become  perfectly  helpless.  The  course  of  the  disease  is  apt 
to  be  a  long  one  of  several  months,  and  in  the  later  stages  atrophy  occurs, 
while  the  early  hyperaesthesia  may  give  place  to  a  more  or  less  marked 

64 


1010  PEDIATRICS. 

anaesthesia,  and  numbness  and  various  otlier  paraesthesite  may  occur.  In 
mild  cases,  where  only  pain  and  tenderness  exist,  the  knee-jerks  may  not 
be  diminished,  and  in  the  early  stages  maybe  even  slightly  increased,  but  in 
the  more  typical  cases  of  the  disease  they  are  absent.  Early  contractures 
and  spasmodic  conditions  are  absent,  the  paralysis  being  flaccid.  The 
bladder  and  rectum  are  not  affected.  The  temperature  is  apt  to  be  some- 
what elevated,  and  is  decidedly  so  at  the  onset  when  the  disease  is  acute. 
The  sensory  symptoms  are  most  marked  in  the  beginning  of  the  attack 
and  subside  more  rapidly  than  the  motor. 

Diagnosis. — The  cUagnosis  is  made  by  the  •  symmetrical  nerve  areas 
being  affected  by  sensory  and  motor  symptoms  and  by  tenderness  of  the 
nerve  trunks.  The  pain  and  tenderness  associated  with  anterior  polio- 
myelitis may  be  due  to  some  degree  of  neuritis,  but  these  cases  do  not 
present  the  anaesthesia  and  paresthesia  of  the  advanced  form  of  neuritis. 
Moreover,  the  paralyses  in  multiple  neuritis  are  symmetrical.  Both 
diseases  generally  show  the  reaction  of  degeneration. 

The  disease  might  in  some  cases  be  mistaken  for  a  form  of  acute 
ascending  paralysis,  known  as  Landry's  paralysis.  This  is,  however,  a 
form  of  paralysis  due  either  to  a  multiple  neuritis  or  to  a  poliomyelitis, 
which  begins  in  the  lower  extremities  and  mvolve  successively  the  aJDdomi- 
nal,  thoracic  and  arm  muscles,  usually  terminating  in  death  from  paralysis 
of  respiration.     It  is  a  rare  condition  in  children. 

Prognosis.  —  The  prognosis  of  multiple  neuritis  is  favorable  even 
when  the  disease  begins  with  an  acute  onset  accompanied  by  delirium 
and  high  fever,  and,  although  the  paralysis  may  last  for  many  months, 
the  cases  usually  recover.  Exceptionally,  however,  the  results  may  be 
permanent,  and  death  may  take  place  from  paralysis  of  the  heart  or  of  the 
muscles  of  deglutition  and  respiration.  When  the  reaction  of  degenera- 
tion is  present  the  prognosis  for  complete  recovery  is  not  so  good  and  the 
case  is  apt  to  be  prolonged. 

Treatment. — The  treatment  is  at  first  by  absolute  rest  in  bed.  and 
later  with  electricity,  massage,  and  strychnine.  The  primary  cause  of 
tlie  disease  having  been  determined,  it  should,  if  possible,  be  removed. 
For  instance,  if  the  child  lives  in  a  malarial  district  it  should  be  taken 
away.  In  case  of  obscure  etiology,  the  urine  should  be  examined  for 
arsenic  or  lead,  and  treated  accordingly. 

The  treatment  of  those  cases  which  follow  the  acute  infectious  dis- 
eases is  symptomatic  and  hygienic.  For  the  pain  the  application  of  heat 
is  the  most  efficacious  remedy.  In  the  acute  cases  electricity  should  be 
begun  after  three  or  four  weeks  :  faradism  should  be  used  if  a  reaction  is 
obtained  with  a  moderate  current,  otherwise  galvanism.  Iodide  of  potas- 
sium is  mdicated  in  those  cases  which  are  caused  by  lead  or  arsenic.  In 
the  subacute  cases  electricity  and  massage  should  be  employed  from  the 
very  beginning.  It  is  safer  to  wait  until  the  pain  and  marked  tenderness 
have  disappeared  before  beginning  the  admkiistration  of  strychnine. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  1011 

The  following  case,  a  giii,  eleven  years  old,  represents  multiple  neuritis  produced 
by  doses  of  1  gramme  (15  minims)  of  Fowler's  solution  given  three  times  a  day  for 
some  weeks  during  an  attack  of  chorea. 

The  first  symptoms  which  were  noticed  while  she  was  taking  the  arsenic  were  that 
she  vomited  several  times,  but  this  was  not  supposed  to  have  been  caused  by  the  arsenic, 
and  the  drug  was  therefore  continued.  It  was  next  noticed  that  the  child  was  unable 
to  walk.  Her  limbs  appeared  to  be  very  weak,  and  there  was  absence  of  knee-jerks 
and  ankle-clonus.  The  sensation  of  the  limbs  was  normal.  A  few  days  later  she  was 
found  to  have  tender  points  over  various  parts  of  the  legs.  The  legs  then  became 
atrophied.  About  a  month  later  tender  points  developed  in  the  arms,  and  she  soon 
lost  the  power  of  using  her  arms,  to  such  a  degree  that  she  had  to  be  fed.  At  this 
time,  although  the  arsenic  had  been  omitted  for  several  days,  a  large  quantity  of  it  was 
found  in  the  urine. 

One  month  later  it  was  found  that  she  could  almost  support  herself  without  assist- 
ance. A  little  later  she  walked  with  crutches,  and  a  month  later  she  could  walk  with- 
out assistance,  but  with  difficulty.  The  knee-jerks  were  still  absent.  She  continued 
to  improve,  and  finally  after  a  number  of  months  recovered  entirely. 

INSULAR  OR  DISSEMINATKD   SCLEROSIS. 

Insular  or  disseminated  sclerosis  is  a  chronic  degenerative  disease  of 
the  brain  and  cord,  characterized  by  multiple  distribution  of  areas  of 
sclerosis. 

Etiology. — The  disease  appears  most  frequently  as  a  result  of  the  spe- 
cific infectious  fevers  and  metallic  poisoning.  Heredity  is  of  some  impor- 
tance in  the  etiology,  chiefly  inasmuch  as  it  predisposes  to  a  neurotic  dispo- 
sition. The  disease  is  most  common  in  the  second  and  third  decades,  but 
many  cases  in  early  life,  even  in  infancy,  have  been  reported. 

Pathological  Anatomy. — The  sclerotic  patches  may  occur  in  the^'brain 
or  cord  or  in  both,  and  are  very  irregular  in  their  distribution  and  size. 
The  Avhite  matter  of  the  brain,  the  pons,  the  medulla,  and  the  lateral 
columns  in  the  dorsal  and  lumbar  regions  are  most  commonly  involved. 
The  sclerosal  patches  consist  of  proliferated  neuroglia,  the  growth  of 
which  destroys  the  myehn  of  the  nerves  with  but  little  destruction  of  the 
axis-cylinder. 

Symptoms. — The  disease  is  generally  slow  in  its  development,  and  is 
characterized  by  tremors  on  attempting  voluntary  motions  {intention 
tremors)  ;  by  scanning  speech^  the  words  being  pronounced  slowly  or  wdth 
accentuation  of  the  syllables  and  distinct  tremulousness  of  the  voice ; 
by  nystagmus^  a  rapid  oscillatory  movement  of  the  eyes,  especially  when 
they  are  moved  laterally  ;  and  by  spastic  paralysis,  the  gait  being  clumsy 
and  staggering.  The  muscles  are  rigid  and  the  deep  reflexes  increased. 
Ocular  disturbances  are  common  and  are  similar  to  those  observed  in 
hysteria.  Inequality  of  the  pupils  and  atrophy  of  the  optic  nerve  may 
occur.     In  the  majority  of  cases  there  is  no  disturbance  of  sensation. 

As  the  disease  progresses  the  speech  becomes  unintelligible,  the  memorj'' 
fails,  and  the  muscular  weakness  and  paralysis  is  more  and  more  marked 
until  the  patient  is  bedridden.  Some  cases  are  of  more  rapid  develop- 
ment that  others.    Some  may  present  bulbar  symptoms  in  which  not  only 


1012  PEDIATRICS. 

the  power  of  speech  but  of  deglutition  and  respiration  is  affected.     Apo- 
plectiform or  epileptiform  seizures  may  occur  in  the  course  of  the  disease. 

Diagnosis. — A  marked  degree  of  muscular  atrophy,  and  changes  in  elec- 
trical reaction  are  not  present  in  multiple  sclerosis,  and  their  absence  is  of 
much  aid  in  the  differential  diagnosis. 

Multiple  sclerosis  may  be  distinguished  from  transverse  myelitis  by 
the  extreme  rarity  of  the  latter  condition  in  early  life,  by  its  acute  onset 
and  the  sensory  symptoms. 

The  diagnosis  from  hereditary  ataxia  is  given  below.  The  nystag- 
mus, scanning  speech,  and  intention  tremor  will  serve  to  distinguish  the 
disease  from  hysteria,  which  it  may  at  times  resemble.  Chorea  may  be 
eliminated  in  the  diagnosis  by  the  absence  of  tremor,  by  the  presence 
of  the  characteristic  incoordinate  movements,  and  by  the  absence  of 
nystagmus  and  true  ataxia. 

Prognosis. — The  disease  is  incurable,  and  may  last  for  years.  Remis- 
sion of  the  symptoms  and  even  improvement  may  occur,  but  the  general 
course  of  the  disease  is  progressive. 

Treatment. — Rest  in  bed,  hydrotherapeutics,  massage,  and  general 
hygiene  are  desirable  in  that  they  alleviate  the  condition,  rendering  life 
more  bearable,  but  no  treatment  can  be  said  to  be  in  any  way  curative. 

HEREDITARY  ATAXIA    (Friedreich's  Disease). 

Hereditary  or  family  ataxia  is  a  comparatively  rare  disease,  dependent 
on  a  slowly  progressive  sclerosis  of  the  cord  at  different  levels,  which 
involves  especially  the  posterior  and  lateral  columns.  It  usually  occurs 
in  several  members  of  a  family,  and  develops  in  late  childhood. 

Symptoms. — The  characteristic  symptoms  are  ataxia  of  the  legs  and 

arms,  gradual  loss  of  muscular  power,  with  atrophy  of  the  muscles,  loss 

of  the  knee-jerks,  disturbance  of  speech,  and,  in  the  late  stages,  nystagmus, 

^muscular  contractures  from  paralysis,  giving  rise  especially  to  scoliosis  and 

club-feet,  and  complete  helplessness,  with  mental  impairment. 

A  cerebellar  form  of  the  disease  has  been  described  by  Marie,  charac- 
terized by  an  increased  knee-jerk,  loss  of  ocular  accommodation,  light 
reflexes,  and  absence  of  deformities,  but  occurs  only  after  pubescence. 

Diagnosis. — The  disease  is  differentiated  from  tabes  dorsalis  by  the 
absence  of  the  crises  and  Argyll-Robertson  pupil  of  tabes,  by  the  heredi- 
tary character  of  the  affection,  and  the  rarity  of  tabes  in  early  life. 

It  is  differentiated  from  multiple  sclerosis  by  the  absence  of  increased 
reflexes,  intention  tremors,  spastic  gait,  and  ocular  palsies. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  of  hereditary 
ataxia  is  always  unfavorable,  and  no  treatment  is  of  benefit  except  for  the 
relief  of  symptoms. 

JUVENILE  TABES  (Locomotor  Ataxia). 
Cases  of  juvenile  tabes  are  still  very  rare.     After  a  most  painstaking 
search  Mowburg  of  Vienna  has  collected  34  cases,  which,  if  critically 


DISEASES   OF   THE   NERA^OUS  SYSTEM.  1013 

analyzed  may  be  reduced  to  20.  The  chief  symptoms  were  loss  of  knee- 
jerks,  Argyll-Robertson  pupil,  ataxia,  lightning  pains,  bladder  disturbance, 
primary  progressive  optic  atrophy,  ptosis,  girdle  sense  and  paraesthesise, 
A  study  of  these  cases  shows  that  in  the  juvenile  form,  vesical  disturb- 
ance and  optical  atrophy,  make  their  appearance  early,  while  ataxia  is 
either  a  late  or  absent  symptom.  Erb  has  maintained  that  juvenile  tabes 
is  always  due  to  syphilis  and  later  reported  cases  seem  to  support  this 
view.     The  disease  may  show  itself  as  early  as  the  eighth  or  tenth  year. 

SYRINGOMYELIA. 

Syringomyelia  is  exceedingly  rare  in  early  life.  It  is  regarded  as  a 
gliosis,  a  development  of  embryonal  neuroglia  tissue  about  the  central 
canal  of  the  spinal  cord,  in  which  hemorrhage  and  degeneration  take 
place  with  the  formation  of  cavities. 

In  this  disease  we  usually  find  a  diminution  of  sensation  to  heat  and 
cold,  accordmg  to  the  site  of  the  lesion,  which  is  commonly  a  point  in  the 
upper  dorsal  or  the  lower  cervical  region.  The  sense  of  touch  is  pre- 
served. There  is  apt  to  be  a  weakness  of  one  or  both  arms,  accompanied 
by  marked  wasting.  There  is  also  usually  some  weakness  in  the  legs. 
The  reflexes  are  increased,  and  a  spastic  condition  is  tikely  to  result. 
These  symptoms  are  usually  accompanied  by  marked  lateral  scoliosis. 

Syringomyelia  is  an  incurable  disease,  and  the  treatment  is  therefore 
usually  limited  to  correcting,  if  possible,  the  lateral  curvature  which 
frequently  accompanies  it. 

HEREDITARY  SPASTIC  PARALYSIS. 
The  term  hereditary  spastic  paralysis  has  been  applied  by  Sachs  to  an 
hereditary  disease  characterized  by  spastic  rigidity,  chiefly  of  the  lower 
extremities.  He  recognizes  two  types  of  the  disease.  One  is  of  spinal 
type,  a  spastic  paraplegia  with  contractures  and  increased  reflexes,  due  to 
interference  with  the  pyramidal  tract  in  the  lateral  column  of  the  cord. 
Another  type,  the  cerebral  type,  develops  at  about  four  or  five  months  of 
ao-e.  It  is  characterized  by  increasing  mental  dulness,  defective  vision, 
ending  in  blindness,  nystagmus,  and  gradual  physical  deterioration.  Con- 
vulsions are  never  present.  The  symptoms  may  continue  for  one  or  two 
years,  but  end  fatally.     The  treatment  is  symptomatic. 

FAMILY  PERIODIC  PARALYSIS. 
Family  periodic  paralysis  is  characterized  by  a  periodic  flaccid  motor 
paralysis  involving  all  the  voluntary  muscles  except  those  of  the  face, 
eyes,  tongue,  speech,  deglutition  and  sphincters.  The  paralysis  may  be 
partial  or  complete  and  in  certain  seizures  only  the  upper  or  lower 
extremities  may  be  involved.  Respiration  may  be  difficult  and  the 
myocardium  so  weakened  as  to  give  rise  to  cardiac  dilatation  during  the 
attack.     There  is  complete  absence  of  reflexes  during  a  severe  attack  and 


1014  PEDIATRICS. 

faradic  irritability  of  tlie  muscle  is  lost.  The  attacks  may  be  precipitated 
by  over-exercise.  Tlie  onset  is  usually  at  night.  Holtzapple  has  reported 
a  family  seventeen  members  of  wliich  -were  afflicted.  In  most  of  these 
cases  tlie  attacks  began  either  at  puberty  or  in  tlie  second  decade.  A  few 
began  as  early  as  the  eighth  and  ninth  years.  Many  cases  are  intimately 
related  to  migraine. 

During  the  periods  between  the  seizures  the  patients  are  perfectly 
well.  The  attacks  may  last  for  hours  or  days,  and  the  duration  is 
uniform  in  a  given  case.  The  paralysis  recedes  in  the  reverse  order  of 
invasion. 

Prognosis. — Some  cases  outgrow  the  tendency  to  the  attacks,  while  in 
the  majority  of  cases  the  disease  may  persist  throughout  life,  it  may  end 
fatally  from  involvement  of  the  muscles  of  the  heart  and  respiration. 
Tliere  is  no  treatment  which  can  be  said  to  influence  the  course  of  the 
disease. 

PROGRESSIVE   CENTRAL  MUSCULAR  ATROPHY. 

Progressive  muscular  atrophy  of  central  origin,  also  described  as  the 
Aran-Duchenne  type,  develops  in  the  great  majority  of  cases  in  adult  life 
after  the  twenty-fifth  year.  A  few  cases,  however,  have  been  reported 
in  young  children,  notably  two  by  Hoffman,  one  of  which  occurred  in  a 
girl  four  years  of  age,  and  another  in  her  brother,  in  whom  the  symptoms 
began  at  about  the  same  age. 

Various  forms  are  recognized  in  adults  and  are  known  as  amyotrophies, 
by  which  is  meant  a  progressive  wasting  due  to  lesions  in  the  spinal  cord, 
as  distinguished  from  the  term  myopatkies  or  dystrophies,  in  which  the  pri- 
mary disease  is  in  the  muscles  themselves.  Midway  between  these  two 
types  of  muscular  atrophies,  both  in  the  pathological  lesions  and  clinical 
symptoms,  is  another,  which  will  be  described  later  as  pyrogressive  neural 
muscular  atrophy. 

Etiology. — The  direct  cause  of  the  progressive  muscular  atrophy  of 
central  origin  is  not  known.  Hereditary  and  family  mfluences  are,  in 
adults,  of  much  less  importance  in  relation  to  this  spinal  type  of  progres- 
sive muscular  atrophy  than  they  are  in  the  muscular  atrophies  of  neural 
origin  and  of  the  dystrophies.  The  association  of  the  disease,  however, 
in  the  children  of  one  family  has  been  noted,  and  is  a  characteristic  of 
the  infantile  form.  Trauma,  exposure  to  wxt,  cold,  fright,  and  nervous 
shock  are  mentioned  as  etiological  factors. 

Pathological  Anatomy. — The  pathological  lesions  consist  primarily  in 
a  slow  degeneration  of  the  upper  and  lower  neurons  of  the  motor  path, 
resulting  in  progressive  atrophy  of  certain  groups  of  muscles.  The  chief 
histological  changes  consist  of  an  atrophy  of  the  ganglion-cells  of  the  ante- 
rior horns  and  an  increase  in  the  neuroglia.  The  lateral  pyramidal  tracts 
may  show  degenerative  changes,  which,  in  some  cases,  have  been  traced 
to  the  motor  cortex,  and  even  to  the  cortical  motor  cells  themselves. 
When  this  is  marked  the  disease  is  called  amyotrophic  lateral  sclerosis. 


DISEASES  OE  THE  NERVOUS  SYSTEM.  1015 

The  direct  cerebellar  and  ventro-lateral  tracts  are  not  involved.  The 
muscles  and  the  inter-muscular  branches  of  the  motor  nerves  show 
degenerative  changes. 

Symptoms. — Indefinite  pains  suggesting  those  of  clironic  rheumatism 
may  be  the  earliest  sjiiiptoms.  Tliese  are  followed  by  a  gradual  loss  of 
power  and  atrophy  of  the  muscles.  The  muscles  of  the  thumb,  both  in 
the  thenar  and  hypothenar  groups,  and  then  the  interossei  and  lumbri- 
cales  are  first  affected,  leaving  depressions  between  the  metacarpal  bones. 
The  wasting  process  then  attacks  the  flexor  and  extensor  muscles  of  the 
forearm,  contractions  set  in,  and  the  characteristic  ''  claw-hand'"  develops. 
The  deltoid  is  the  first  of  the  shoulder  muscles  to  atrophy,  and  then 
follow  in  the  typical  cases  the  remaining  muscles  of  the  upper  extremity, 
the  muscles  of  the  trunk,  and  finally  those  of  the  lower  extremity.  The 
trapezius  and  face  muscles  are  among  the  first  to  be  attacked.  This  order 
of  progression  is  not  always  maintained.  In  rare  cases  the  legs  may 
begin  to  atrophy  soon  after  the  affection  of  the  hand.  Muscular  con- 
tractures from  the  action  of  antagonistic  muscles,  fibrillar}'  t\\itcliing  in 
the  unaffected  muscles,  numbness  and  coldness  in  the  regions  of  atrophy, 
and  diminution  and  even  loss  of  muscular  reaction  to  faradic  and  galvanic 
currents  are  generally  present  in  advanced  cases.  The  reaction  of  degen- 
eration maybe  present  in  the  muscles  in  which  the  atrophy  is  extreme. 
The  excitability  of  the  nerve  trunks  outlasts  that  of  the  muscles.  The 
muscular  weakness  is  proportionate  and  generally  dependent  upon  the 
degree  of  atrophy.     Sensation  of  heat,  touch,  and  pain  is  not  impaired. 

In  another  type  of  cases,  described  by  Charcot  as  amyotrophic  laterul 
sclerosis,  a  spastic  paralysis  is  associated  with  the  wasting  and  is  due  to 
degeneration  of  the  pyramidal  tracts,  but  so  far  as  we  know  this  condition 
does  not  occur  in  children. 

In  very  rare  cases  in  children  the  degenerative  processes  may  affect 
the  nuclei  of  the  motor  cranial  nerves,  both  the  upper  and  lower  divisions 
of  the  motor  tract  being  involved  (Sachs).  The  symptoms  in  these  cases 
bear  a  close  resemblance  to  the  progressive  bulbar  paralyses  of  adults, 
but  are  so  rare  that  they  need  merely  be  referred  to. 

Diagnosis. — ^The  diagnosis  is  made  on  the  slow,  progressive  wasting 
of  muscles  in  the  order  described,  on  the  gradual  loss  of  power  in  the 
affected  groups,  on  the  fibrillary  muscular  contractions,  on  the  diminution 
in  the  electrical  reactions,  on  the  absence  of  marked  impairment  of  sensa- 
tion, and,  in  the  great  majority  of  cases,  on  the  absence  of  hereditary  or 
family  influences.  The  rarity  of  the  disease  in  early  life  is  also  of  some 
value  in  the  diagnosis.  It  is  to  be  distinguished  from  ulnar  neuritis'  and 
svrins-omyelia  by  the  absence  of  disturbance  of  sensation. 

Prognosis. — The  disease  is  progressive  and  may  last  for  many  years. 
It  is  invariably  fatal,  although  there  may  be  periods  in  which  there  is  an 
apparent  arrest  of  the  process,  but  which  is  only  temporary. 

Treatment. — The  treatment  is  at  best  palliative  and  for  the  most  part 


1016  PEDIATRICS. 

ineffective.  Massage,  electricity,  anti-specific  treatment  if  there  is  any 
evidence  of  a  tiyphilitic  taint,  arsenic,  and  hypodermic  injections  of  strych- 
nine, as  recommended  by  Powers,  may  be  tried. 

PROGRESSIVE  NEURAL  MUSCULAR  ATROPHY. 

Progressive  neural  muscular  atrophy  is  also  known  as  the  peroneal,  or 
leg  type  of  progressive  muscular  atrophy. 

Etiology. — The  disease  is  an  hereditary  or  family  affection,  beginning  in 
very  early  life  in  the  cases  reported  by  Sachs,  and  as  late  as  twenty  years 
in  the  case  described  by  Charcot  and  Marie.  Dubreuilh  has  reported  a 
fatal  and  very  typical  case  in  a  child  in  a  family  in  which  the  mother  and 
eleven  children  were  similarly  affected. 

Pathological  Anatomy. — The  pathological  conditions  found  in  Du- 
breuilh's  case  showed  chronic  degenerative  changes  in  the  peripheral 
nerves,  without  lesions  in  the  gray  substance  of  the  spinal  cord,  with  the 
exception  of  a  very  slight  increase  in  the  glia  of  the  column  of  Goll.  The 
motor  nerves  of  the  hands  and  feet  were  especially  involved.  The 
muscles  showed  atrophy  of  the  fibres  ;  some  were  degenerated  and  some 
were  hypertrophied.  The  transverse  striations  were  diminished  and  the 
nuclei  increased.  According  to  Sachs,  these  muscular  changes  more  closely 
resemble  those  which  occur  in  the  primary  dystrophies  than  those  which 
are  dependent  on  changes  in  the  spinal  ganglia,  and  the  slight  lesions  in  the 
cord  are  probably  secondary  to  those  in  the  peripheral  nerves.  As 
this  class  of  cases  is  intermediate  between  those  of  central  origin  and  the 
primary  dystrophies,  he  considers  the  neural  origin  of  the  disease  a  theory 
to  be  accepted  with  reserve  until  verified  by  other  cases. 

Symptoms. — The  peroneal  muscles  and  the  muscles  of  the  feet  are  the 
first  to  be  affected,  atrophy  sets  in,  contractions  of  antagonistic  muscles 
follow,  and  end  in  the  production  of  club-foot,  either  pes  equinus  or  pes 
-equino-varus.  Eventually  the  entire  leg  may  atrophy.  The  upper  ex- 
tremities and  body  are  rarely  affected  until  late  in  the  disease,  and  the 
atrophy  is  not  so  marked  as  in  the  cases  of  central  origin.  In  very  rare 
instances  the  disease  may  begin  in  the  hands.  Fibrillary  contractions  and 
twitchings  are  present.  The  electrical  reactions  of  both  muscles  and  nerves 
are  much  diminished.  The  reflexes  of  the  lower  extremities  are  either  lost 
or  diminished.  The  sensations  may  be  either  normal  or  slightly  altered ; 
the  sense  of  pain  is  sometimes  increased.  Muscular  weakness  propor- 
tionate to  the  atrophy  and  deformity  is  present,  and  gives  rise  to  a  wad- 
dling gait,  and  especially  to  difficulty  in  going  up-stairs. 

Diagnosis. — The  diagnosis  of  progressive  neural  muscular  atrophy  is 
to  be  made  from  several  similar  conditions. 

From  Progressive  Muscular  Atrophy  of  Central  Origin. — This  may  be 
necessary  in  those  cases  in  which  atrophy  of  the  lower  extremities  follows 
soon  after  the  affection  of  the  hands.  The  rarity  of  this  condition  in  early 
life,  the  absence,  as  a  rule,  of  hereditary  influences,  and  the  normal  sen- 


DISEASES   OF   THE   NERVOUS   SYSTEM.  1017 

sation  are  the  only  points  in  the  differential  diagnosis.  Typical  cases  of 
either  disease  are  readily  distinguished  by  the  onset  and  manner  of 
progression,  but  in  atypical  cases  the  differential  diagnosis  may  not  be 
possible. 

From  Poliomyelitis. — In  poliomyelitis  the  sudden  onset,  retrogressive 
character  of  the  atrophy,  the  absence  of  hereditary  influences,  and  fibril- 
lary contractions,  and  the  absence  rather  than  diminution  of  knee-jerks 
serve  to  distinguish  the  disease  from  the  slowly  progressive  hereditary 
paralysis  which  has  just  been  described.  The  diagnosis  from  the  sub- 
acute and  chronic  forms  of  poliomyelitis  is  often  difficult  until  the  progres- 
sive character  of  the  disease  becomes  apparent. 

From  Hereditary  Ataxia. — The  absence  of  ataxia,  the  abnormal  electri- 
cal reactions,  and  the  persistence  of  the  reflexes  in  certain  cases  of  pro- 
gressive neural  muscular  atrophy  render  the  diagnosis  from  hereditary 
ataxia  clear  in  most  cases. 

From  Chronic  3Iultiple  Neuritis. — In  the  muscular  atrophy  dependent 
upon  neuritis,  the  greater  prominence  of  pain  and  tenderness,  the  absence 
of  hereditary  or  family  influences,  and  the  extreme  rarity  of  the  develop- 
ment of  double  club-foot  generally  enables  us  to  distinguish  neuritis  from 
progressive  neural  muscular  atrophy. 

Dejerine  and  Soltas  have  described  a  family  disease  of  rare  occurrence 
beginning  early  in  life  and  resembling  in  many  respects  a  progressive 
neural  muscular  atrophy.  It  is  characterized  by  the  symptoms  of  tabes 
dorsalis  combined  with  progressive  muscular  atrophy  involving  the  face 
and  lips  and  by  an  interstitial  hypertrophic  neuritis  extending  into  the 
dorsal  columns  of  the  cord.  The  condition  is  sometimes  cdlXe^ progressive 
interstitial  hypertrophic  neuritis  of  infants. 

Prognosis. — The  duration  of  the  disease  is  very  chronic,  but  there  may 
be  periods  of  arrest  in  its  development,  during  which  the  health  of  the 
patient  remains  fairly  good. 

Treatment.— The  disease  is  incurable.  Much  can  be  done  by  ortho- 
pgedic  surgery  for  the  relief  of  deformities  produced  by  the  contractions. 
Massage  and  electricity  are  the  main  indications  for  treatment.  There  is 
no  effective  medicinal  treatment. 

PROGRESSIVE  MUSCULAR  DYSTROPHIES. 

Classification. — The  group  of  diseases  known  as  primary  muscular  dys- 
trophies, or  primary  myopathies,  are  represented  by  several  forms,  which 
differ  from  progressive  muscular  atrophy  of  central  origin  (Aran-Duchenne 
type)  in  that  the  lesions  are  primary  in  the  muscles  and  are  not  dependent 
upon  degenerative  changes  in  the  spinal  cord. 

For  the  sake  of  convenience  Erb  has  divided  the  muscular  dystrophies 
into  two  large  groups,  which  are  still  further  subdivided  into  types  de- 
pendent partly  on  pathological  and  partly  upon  clinical  differences.  This 
classification  may  be  expressed  as  fohows  : 


1018  PEDIATRICS. 

I.  Progressive  Muscular  Dystrophy  of  Infancy. 

A.  Hypertrophic  Form,  in  which  the  muscles  are  increased  in 

size,  and  eventually  becomes  atrophic. 

a.  With  real  hypertrophy  of  the  muscle  fibres. 

b.  With  false  hypertrophy,  the  muscular  fibres  having  un- 

dergone lipomatosis. 

B.  Atrophic  Form,  in  which  there  is  no  stage  of  hypertrophy. 

a.  The  Landouzy-Dejerine  type,  in  which  there  is  primary 

involvement  of  the  face. 

b.  An   atrophic    form   without   involvement   of  the   facial 

muscles. 

II.  Progressive  Muscular  Atrophy  of  Youth  and  Adult  Life.     This  is 

also  known  as  ErVs  juvenile  form. 

All  these  forms  have  certain  points  in  common.  There  is  a  distinct 
hereditary  influence  or  family  association.  The  electrical  reactions  are 
quantitatively  but  not  qualitatively  diminished  in  all,  but  none  show  a 
typical  reaction  of  degeneration.  The  reflexes  diminish  proportionately 
to  the  degree  of  muscular  atrophy.  As  Sachs  has  pointed  out,  the  chief 
distinction  therefore  between  these  clinical  types  is  in  reference  to  the 
distribution  of  the  atrophy  or  hypertrophy. 

Etiology  of  the  Muscular  Dystrophies. — Heredity  or  association  of 
cases  in  one  family  are  the  only  etiological  factors  of  any  importance,  so 
far  as  is  known.  This  peculiarity  serves  as  the  most  important  point  in 
the  diagnosis  of  the  dystrophies  from  progressive  central  muscular  atro- 
phy, almost  all  cases  of  which,  except  Erb's  infantile  form,  are  free  from 
hereditary  influences.  The  disease  is  usually  transmitted  through  the 
mother,  who  may  not  herself  be  affected,  may  run  through  as  many  as 
five  generations,  and  generally  attacks  the  males.  The  disease,  as  a  rule, 
jDegins  before  puberty,  rarely  after  the  twentieth  year. 

Pathological  Anatomy. — The  chief  histological  changes  in  the  muscular 
dystrophies  consist  in  hypertrophy  and  atrophy  of  the  muscular  fibres, 
with  proliferation  of  the  nuclei,  vacuolization  and  segmentation  of  the 
fibres.  The  hypertrophy  of  the  muscle  fibres  appears  to  be  an  early 
process  in  all  forms  of  muscular  dystrophies,  and  is  associated  with  lipo- 
matosis and  changes  in  the  connective  tissue.  Atrophy  of  the  muscle 
fibres  is  a  later  stage  of  the  disease.  No  sharp  distinction  histologically 
can  be  drawn  between  the  muscular  lesions  of  the  spinal  amyotrophies 
and  the  muscular  dystrophies,  as  hypertrophy  of  the  muscle  fibres  may 
rarely  occur  in  the  spinal  amyotrophies  (Sachs).  The  dystrophies  are, 
however,  not  associated  with  lesions  of  the  central  nervous  system. 

Symptoms. — Pseudo-Hypertrophic  Forms.  —  The  earliest  symptoms 
noticed  are  Aveakness  of  the  muscles,  a  waddling,  clumsy  gait,  and  awk- 
wardness in  the  ordinary  motions,  especially  in  rising  from  the  floor  or 
climbing   stairs.      These    symptoms  generally  precede    any   noticeable 


DISEASES   OF   THE  NERVOUS   SYSTEM.  1019 

enlargement  of  the  muscles.  Gradually,  however,  the  muscles  of  the 
calves  increase  in  size  and  are  hard  and  firm.  The  deltoid,  supra-,  and 
infra-spinati  muscles  are  similarly  affected.  The  thighs  are  rarely  hyper- 
trophied.  Atrophy  of  the  thighs  and  of  the  deep  muscles  of  the  back 
and  shoulder  sets  in.  The  atrophy  of  the  serratus  magnus  gives  the 
characteristic  "angel-wing  scapulge."  Late  in  the  disease  the  atrophic 
process  becomes  general,  affecting  even  the  hypertrophied  calves.  The 
muscles  of  the  face  are  not  involved  until  in  the  very  last  stages. 

Children  who  are  affected  with  this  form  of  dystrophy  learn  to  walk 
late,  and  assist  themselves  by  leaning  on  the  furniture  or  other  objects  in 
their  path.  When  the  child  is  placed  on  the  floor  on  its  back  it  has 
difficulty  in  getting  up.  It  has  to  turn  over  on  its  face  first,  and  then  to 
aid  the  weakened  muscles  of  the  legs  and  trunk  by  means  of  the  hands 
and  arms,  climbing  up,  as  it  were,  upon  itself  by  placing  the  hands  upon 
the  knees  and  then  farther  and  farther  up  the  thighs.  Fibrillary  con- 
tractions do  not  occur.  The  knee-jerks  in  some  cases  disappear  as  the 
disease  advances.  Sensation,  as  a  rule,  is  normal.  There  is  seldom 
any  disturbance  of  the  bladder  or  rectum. 

In  the  later  stages  of  the  disease  contractions  of  the  muscles  occur, 
and  in  this  way  permanent  distortions  of  the  joints  may  result.  The 
most  common  deformities  are  talipes  equinus  and  flexion  of  the  knees  and 
hips. 

Lateral  curvature  occurs,  or  a  permanent  flexion  of  the  spine  from 
weakness  of  the  erector  spinge  muscles  may  result  so  that  the  child  sits 
bowed  forward,  or  when  kneeling  on  the  hands  and  feet  there  is  a 
saddle-shaped  depression  of  the  back.  The  electrical  reactions  show  only 
quantitative  changes.     The  reaction  of  degeneration  is  never  present. 

Atrophic  Form. — This  form  is  known  as  the  Landouzy-Dejerine  type. 
The  muscles  of  the  face  and  shoulder  are  primarily  affected;  there  is  no 
hypertrophy  except  in  very  rare  instances.  The  muscles  of  the  forearm, 
hands,  legs,  and  back  remain  unaffected.  Westphal  has  described  a  case  in 
which  the  face  muscles  were  involved  in  an  otherwise  typical  case  of  pseudo- 
hypertrophy. Other  forms  occur  without  involvement  of  the  facial  mus- 
cles.    The  Landouzy-Dejerine  type,  therefore,  is  not  absolutely  distinctive. 

Brb's  Juvenile  Form. — The  shoulder  muscles  are  primarily  affected. 
The  disease  beghis  in  late  childhood  or  early  youth,  and  is  characterized 
by  progressive  atrophy  of  the  muscles  of  the  shoulder,  upper  arm,  pelvis, 
thio-h,  and  back,  the  forearm  and  legs  remaining  normal.  True  or  pseudo- 
hypertrophy may  be  associated  with  the  atrophy  in  certain  groups  of  mus- 
cles, notably  in  the  deltoids,  supra-spinati  and  infra-spinati  muscles. 

Diagnosis. — The  differential  diagnosis  of  progressive  muscular  dystro- 
phies presents  many  difficulties,  and  depends  primarily  upon  the  distribu- 
tion of  the  lesions.     In  other  respects  they  may  be  practically  the  same. 

The  group  differs  from  the  spinal  or  central  form,  however,  in  the  he- 
reditary character  of  the  affection,  in  the  primary  appearance  and  the  distri- 


1020 


PEDIATRICS. 


bution  of  the  lesions,  in  the  absence  of  fibrillary  contractions,  in  the  absence 
of  marked  electrical  changes,  and  in  their  greater  frequency  in  early  life. 

The  chief  point  in  the  diagnosis  from  progressive  neural  muscular 
atrophy  is  in  the  peculiar  distribution  of  the  atrophy  in  the  latter  affection 
to  the  muscles  of  the  feet  and  to  the  peroneal  group. 


Fig.  210. 


Fig.   211. 


Pseudo-hypertrophic     muscular     paralysis, 
showing  enlarged  calves. 


Pseudo-hypertrophic  muscular  paralysis,  showing 
position  assumed  in  rising  from  the  floor. 


Prognosis. — All  forms  of  the  muscular  dystrophies  are  slowly  pro- 
gressive and  are  incurable.  The  pseudo-hypertrophic  type  may  render 
the  patient  a  helpless  cripple  in  two  or  three  years.  The  other  forms 
may  last  for  ten,  twenty,  or  thirty  years,  but  the  patient  is  very  suscep- 
tible to  intercurrent  diseases. 

Treatment. — The  treatment  is  very  limited  and  does  not  differ  from 
that  of  progressive  central  muscular  atrophy  described  on  page  1014. 

Fig.  210  illustrates  the  hypertrophy  of  the  calves  which  occurs  in  the 
pseudo-hypertrophic  form  of  progressive  muscular  atrophy.  Fig.  211 
represents  a  child  in  the  characteristic  act  of  "  climbing  up  on  himself.  " 


DIVISION    XVII. 

UNCLASSIFIED    DISEASES. 


H^gEMOPHILIA. 

In  contradistinction  to  the  hemorrhages  of  infectious  origin  which 
occur  in  the  early  weeks  of  life  is  that  class  of  hemorrhages  which  can 
be  classed  under  the  term  hcemQphilia. 

Haemophilia  simply  means  a  morbid  condition  characterized  by  a  ten- 
dency to  bleed  spontaneously  or  from  any  insignificant  wound.  Indi- 
viduals who  are  liable  to  bleed  in  this  way  are  designated  as  having 
a  hemorrhagic  diathesis.  The  disease  is  very  uncommon  in  the  early 
weeks  of  life,  and  usually  occurs  at  a  later  period  of  development.  It 
begins  to  be  more  frequent  towards  the  end  of  the  first  year,  and  is 
apparently  well  established  in  the  second  year  and  later  in  childhood. 
It  does  not  have  a  self-limited  course,  as  is  the  case  with  the  other  form 
of  hemorrhage.  It  is  not  infectious,  and  is  not  accompanied  by  fever. 
It  may  be  for  many  years  masked,  and  then  may  become  manifest  from 
some  trivial  cause,  such  as  the  extraction  of  a  tooth.  It  is  a  dangerous 
disease,  and  death  is  verj''  liable  to  occur  ft-om  inability  to  control  the 
hemorrhage.  The  condition  is  hereditary,  being  transmitted  usually,  but 
not  always,  through  the  females  to  the  males,  but  seldom  occurring  in  the 
females,  the  proportion  being  one  to  eleven  or  thirteen  (Osier). 

Larrabee  has  collected  33  cases  of  haemophilia  in  the  new-born, 
accepting  as  proof  of  the  accuracy  of  the  diagnosis  (1)  a  distinct  history  of 
haemophilia  in  the  family,  and  (2)  of  haemophilia  in  later  life  in  infants  who 
recovered  from  hemorrhages  in  the  early  days  of  life.  Twenty-two  of 
these  babies  died.  Eleven  cases  were  positive  by  both  criteria.  In  his 
series  twenty-seven  were  males  and  six  females. 

In  addition  to  the  hemorrhage  which  occurs  in  various  parts  in 
heemophilia  Konig  describes  a  condition  of  the  joints  which  for  a  long 
time  was  supposed  to  be  of  gouty  origin.  This  affection  of  the  joints 
like  other  hemophilic  hemorrhages,  occurs  most  commonly  in  boys  and 
young  men.  The  onset  of  the  attack  is  sudden,  and  often  without  any 
history  of  trauma.  The  effusion  into  the  joint  is  found  to  be  of  pure 
blood,  and  the  quantity  may  be  largo.  This  effusion  may  be  entirely 
absorbed  spontaneously,  or  may  occur  later  in  the  same  joint  or  else- 

1021 


1022  PEDIATRICS. 

where.  Shaw  reports  a  case  in  which  the  recurring  effusion  into  and 
about  the  joints  was  regularly  preceded  by  a  definite  prodromal  dis- 
comfort in  the  joint.  After  repeated  attacks,  chronic  joint  changes  may 
ensue.  There  is  no  tendency  to  suppuration.  The  effusion  sometimes 
occurs  about,  rather  than  in  the  joint.  The  disease  is  Hable  to  be  mis- 
taken for,  and  is  to  be  differentiated  from,  tumor  albus  and  tubercu- 
losis. Careful  attention  to  personal  and  family  history  is  the  only  safe- 
guard in  making  a  diagnosis  of  this  disease,  although  we  should  always 
bear  in  mind  the  possibility  of  its  presence  in  case  of  a  sudden  onset 
of  the  affection  of  a  joint  in  a  young  male  and  without  history  of  severe 
traumatism. 

Treatment. — There  is  no  treatment  which  has  been  found  successful 
in  these  cases  beyond  the  active  local  emplojTnent  of  stj-ptics  and  com- 
pression.    Gelatin  and  suprarenal  extract  should  be  tried  (page  308j. 

PURPURA. 

Purpura  is  a  term  applied  to  certain  conditions  in  which  there  are 
hemorrhages  into  the  skin  or  mucous  membranes.  These  hemorrhages 
may  be  of  various  sizes.  ^Mien  small,  they  are  called  petecliiee ;  when 
larger,  they  are  called  ecchymoses.  There  is  no  proof  that  purpura  is  a 
disease  of  the  blood.  Its  etiology  is  very  obscure,  and  although  this  con- 
dition has  been  divided  into  various  forms,  such  as  purpura  simplex  and 
purpura  hemorrhagica,  it  is  doubtful  whether  these  are  not  all  microbic  in 
their  origin  and  simply  represent  different  degrees  of  infection. 

In  the  more  simple  forms  of  purpura  the  hemorrhages  are  only  ui  the 
skin,  while  in  the  more  severe  affection  the  mucous  membranes  of  the 
mouth  and  gastro-enteric  tract  are  usually  mvolved. 

Not  only  does  purpura  occur  in  what  may  be  called  priman'  forms, 
but  this  purpuric  condition  may  also  be  secondary  to  a  number  of  dis- 
eases, especially  those  of  an  exhausting  nature.  Thus,  we  have  seen  it  in 
the  more  severe  and  later  stages  of  infantile  atrophy,  in  which  the  hem- 
orrhages may  cover  almost  the  entire  front  of  the  body.  It  may  also  be 
a  symptom  in  the  more  severe  cases  of  measles,  scarlet  fever,  varicella, 
variola,  diphtheria,  and  in  the  course  of  a  prolonged  rheumatic  attack. 

In  an  infant  who  died  of  infantile  atrophy  at  the  Infants'  Hospital  the  skin  of  the 
extremities  showed  numerous  ecchymoses  of  various  sizes  and  of  a  dark  red  and  pur- 
ple color.  On  the  thorax  on  both  sides  above  the  nipples  were  two  large  ecchymoses, 
and  there  were  smaller  ecchymoses  all  over  the  rest  of  the  trunk.  On  post-mortem 
examination  nothing  abnormal  was  found  except  a  slight  atelectasis  of  the  lower  lobes 
of  both  lungs,  with  pleuritic  adhesions  at  the  base  of  the  right  lung  and  slight  granular 
degeneration  of  the  heart,  liver,  and  kidneys,  with  hyperplasia  of  the  mesenteric  lymph- 
nodes. 

Purpiira  Simplex. — In  the  simple  forms  of  purpura  the  disease  in 
children  is  often  mild,  and  is  accompanied  by  a  loss  of  appetite,  slight 
anaemia,  a  slight  degree  of  fever,  and  the  appearance  of  petechise  in  va- 


UNCLASSIFIED    DISEASES.  1023 

rious  parts  of  the  skin.  The  prognosis  is  good,  and  the  duration  of  these 
attacks  is  usually  from  one  to  two  weeks.  They  are  at  times  associated 
mih  pains  located  in  various  places. 

Purpura  Rheumatica. — The  form  w-hich  has  been  called  purpura 
rheumatica  {peliosis  rheumatica;  Schonlein's  disease)  probably  has  no  con- 
nection with  rheumatic  fever  beyond  the  possibility  of  their  both  being  mi- 
crobic,  and  it  merely  simulates  rheumatic  arthritis  from  the  fact  that  it  affects 
the  joints.  The  diagnosis  is  made  by  the  characteristic  association  of  mul- 
tiple arthritis  with  purpura  and  urticaria. 

Henoch's  Purpura. — Closely  simulating  and  probably  representmg 
purpura  rheumatica,  except  that  the  gastro-enteric  symptoms  are  more 
prominent,  is  a  form  which  has  been  called  Henoch's  purpura.  It  occurs 
especially  in  children  between  the  ages  of  three  and  nine  years.  Its  direct 
cause  is  not  known,  although  it  usually  occurs  among  children  who  have 
had  bad  hygienic  surroundings  and  have  been  ill  cared  for. 

Symptoms. — The  symptoms  are  more  or  less  malaise,  and  pains  not 
especially  localized,  but  chiefly  occurring  in  the  extremities  and  back, 
sometimes  accompanied  by  slight  oedema  of  the  part  affected.  These 
early  symptoms  of  pain  occur  m  one  or  more  joints,  usually  on  the  outer 
sides,  and  sometimes  there  are  swelling  and  redness  simulating  rheumatic 
fever.  In  this  stage  there  may  be  a  sudden  rise  of  temperature. 
Accompanying  these  symptoms  there  may  be  a  few  purpuric  spots,  but, 
as  a  rule,  there  is  a  period  of  several  days  between  the  appearance  of  the 
pains  in  the  joints  and  the  purpuric  appearances  on  the  skin.  The  pur- 
puric spots  may  coalesce,  and  thus  form  ecchymoses  of  various  sizes 
and  colors.  They  are  very  apt  to  begin  on  the  lower  leg  and  spread  up 
to  the  thighs,  genitals,  and  body.  Somewhat  later  intestinal  symptoms 
develop.  While  the  purpura  is  spreading  there  is  severe  colic,  and  the 
pain  is  Yerj  intractable  to  treatment.  The  abdomen  is  retracted  and 
tender.  There  is  obstinate  vomiting.  The  pulse  is  weak,  and  the  face 
has  an  anxious  expression.  There  is  more  or  less  diarrhoea,  which  usually 
occurs  at  the  end  of  an  attack  of  colic.  The  colic  and  vomiting  some- 
times last  for  one  or  two  days.  There  may  be  a  little  blood  in  the  vomitus 
and  in  the  movements.  The  vomiting  then  diminishes,  the  colic  ceases, 
and  later  the  diarrhoea  stops,  the  pain  in  the  joints  passes  away,  the  pur- 
puric spots  gradually  fade  and  disappear,  and  the  child,  although  left  in  an 
exhausted  condition,  is  otherwise  Avell. 

There  are  very  apt  to  be  relapses,  which  may  appear  within  a  few 
days  or  not  for  several  weeks. 

These  are  the  symptoms  of  a  typical  case  ;  but  there  are  many  varia- 
tions. As  a  rule,  the  younger  the  child  the  more  typical  is  the  case. 
Sometmies  the  purpuric  spots  closely  simulate  urticaria.  They  may  occur, 
although  rarely,  in  the  mouth.  They  sometimes  simulate  the  lesions  of 
erAi;hema  nodosum.  The  attacks  of  colic  have  a  paroxysmal  character. 
There  may  be  swelling  of  the  joints, 


1024  PEDIATRICS. 

The  disease  is  rarely  fatal  unless  it  is  complicated  by  some  such  dis- 
ease as  nephritis  or  endocarditis.     The  treatment  is  purely  symptomatic. 

Purpura  Haemorrhagica. — The  most  seA'ere  form  of  purpura  "\vhich 
occurs  is  that  Avhich  is  called  purpura  hasmorrhagica  (morbus  maculosus 
Werlhofii).  The  hemorrhages  in  this  form  are  from  the  mucous  mem- 
branes as  well  as  into  the  skin.  The  disease  begins  with  debility.  A  few 
days  later  purpuric  spots  appear  on  the  skin,  and  sulDsequently  htema- 
turia  and  haemoptysis  occur,  froni  which  excessive  aucemia  may  result. 
There  is  usually  slight  fever.  When  recovery  takes  place  it  is  gradual, 
usually  occupying  two  or  three  weeks. 

l^\iQ  prognosis  \s  unfavorable  m  early  life,  as  death  may  take  place  from 
the  exhaustion  following  loss  of  blood  or  from  hemorrhage  into  the  brain. 
The  diagnosis  of  purpura  haemorrhagica  is  to  be  made  from  scorbutus  by 
the  general  history  of  the  case,  and  by  the  absence,  if  teeth-  are  present, 
of  stomatitis  ulcerosa. 

Purpura  Fulminans. — A  very  malignant  purpura  haemorrhagica  may 
occur,  sometimes  proving  fatal  ^^itMn  twenty-four  hours.  This  form  of 
purpura  is  usually  spoken  of  as  purpura  fulmmans.  It  is  most  commonly 
met  with  in  infants  and  in  very  young  cliildren,  and  is  characterized  by 
cutaneous  hemorrhages  which  develop  with  great  rapidity,  death  some- 
times taking  place  before  there  ha?  been  any  hemorrhage  from  the  mu- 
cous membranes.  We  have  met  with  reports  of  only  seven  or  eight 
cases  of  the  malignant  form  of  purpura. 

The  following  case  represents  tliis  severe  form  of  purpura  : 

An  infant,  seven  months  old,  had  always  heen  perfectly  well,  and  was  being 
nursed  by  its  mother,  who  was  a  healthy,  strong  woman,  and  had  a  number  of  other 
healthy  children.  The  father  was  also  a  remarkably  strong  and  well  man.  This 
infant,  without  noticeable  previous  symptoms,  suddenly  developed  a  severe  form  of 
purpura.  Large  ecchymoses  appeared  upon  the  buttocks  and  on  the  trunk,  and  the 
infant  rapidly  failed  in  strength,  and  died  in  twenty-four  hours.  There  was  no 
hemorrhage  from  the  mucous  membranes. 

STATUS  LYMPHATICUS    .  Lsnnphatism) . 

Lymphatism  is  a  term  which  has  been  given  to  a  condition  which 
occurs  chiefly  in  childhood,  and  is  characterized  by  a  hyperplastic  condi- 
tion of  the  lymph-tissues  and  lymphoid  bone-marrow  tliroughout  the 
body. 

The  term  status  lymphaticus  is  applied  to  a  condition  of  lymphatism  in 
whicli  the  thymus  gland  is  greatly  enlarged  and  clinically  is  associated 
with  convulsions,  asphyxia,  and  often  with  sudden  death. 

Etiology. — The  cause  of  this  condition  is  not  known.  It  has  been 
found  in  connection  with  rhacliitis  and  hypoplasia  of  the  heart  and  aorta. 
Unhygienic  surroundings  tend  especially  to  iDroduction  of  the  disease,  and 
heredity  seems  to  be  a  factor  in  the  etiology.  It  occurs  usually  in  the 
latter  half  of  the  first  year.     The  theory  that  the  symptoms  are  caused  by 


UNCLASSIFIED   DISEASES.  1025 

pressure  does  not  explain  all  cases,  although  pressure  is  undoubtedly  a 
factor,  especially  in  the  production  of  dyspnoea  and  asphyxia. 

Pathological  Anatomy. — The  lymphatic  tissues  are  generally  hyper- 
plastic, but  the  proliferation  is  especially  marked  in  the  pharj'ngeal, 
thoracic,  and  abdominal  groups  of  lymph-nodes.  The  enlargement  of 
the  spleen  is  moderate  and  its  tissues  are  soft  and  hypersemic.  The 
thymus  is  large  and  may  be  ten  centimetres  in  length,  and  as  much  as 
eight  times  its  usual  first  weight  of  7.7  grammes.  Hypoplasia  of  the  bone- 
marrow,  heart,  aorta,  and  thyroid  gland  is  present. 

Symptoms. — The  symptoms  of  status  lymphaticus  are  those  which  may 
occur  in  any  case  of  lowered  vitality,  but  distinct  clinical  features  do  not 
exist. 

The  only  evidence  of  the  disease  may  be  sudden  death  occurring  in 
apparently  healthy  infants,  or  after  some  minor  operation,  or  in  the  course 
of  diseases  in  which  a  sudden  fatal  ending  would  be  extremely  unusual. 
In  other  cases  the  symptoms  may  be  ushered  in  with  convulsions,  cyanosis 
and  fever,  and  progress  rapidly  to  a  fatal  termination.  Again,  asphyxia 
may  be  the  only  symptom,  occurring  in  repeated  attacks  and  generally 
terminating  in  death. 

Dl\gxosis. — The  diagnosis  is  not  easily  made.  It  depends  upon  the 
recognition  of  the  general  lymphatic  enlargement  and  the  exclusion  of 
other  causes,  such  as  tuberculosis  and  leukaemia  and  the  occurrence  of 
the  symptoms  described. 

Prognosis. — The  vitality  of  the  child  is  distinctly  lowered  in  the  con- 
dition of  lymphatism  and  it  is  especially  susceptible  to  the  toxic  actions 
of  the  acLite  infectious  diseases.  At  the  same  time  there  is  a  tendency  to 
outgrow  the  condition  as  puberty  approaches,  so  that  with  careful 
management  the  prognosis  may  become  favorable.  The  prognosis  in 
status  lymphaticus  is  very  grave. 

Treatment. — The  treatment  is  essentially  symptomatic,  and  consists 
chiefly  in  the  regulation  of  the  food  and  hygiene  of  the  child.  Intubation 
in  the  attacks  of  cyanosis  is  unavailing.  Stitching  the  thymus  to  the 
sternum  to  relieve  pressure  has  not  given  more  than  temporary  relief  in 
the  majority  of  cases. 

MYALGIA. 

Myalgia  is  an  affection  characterized  by  pain  and  stiffness  in  certain 
groups  of  muscles.     It  may  be  acute  or  chronic. 

Etiology. — The  disease  is  usually  seen  in  children  between  the  ages 
of  five  and  fifteen,  and  generally  follows  exposure  to  cold  or  dampness 
and  to  bad  hygienic  surroundings.  It  has  been  held  by  Leube,  Peltessohn, 
and  others  to  be  due  to  infectious  micro-organisms,  but  there  is  as  yet  no 
proof  of  this. 

Symptoms. — Pain  on  movement  and  tenderness  and  stitfness  of  certain 
muscles  are  the  typical  symptoms.     Fever  is  rarely  present.     The  pain  is 

65 


1026  PEDIATRICS.^ 

at  times  quite  severe,  slight  movements  of  the  muscles  bringing  on  sharp 
exacerbations.  Certain  names  have  been  given  according  to  the  group  of 
muscles  affected,  such  as  cervicodynia,  or  acute  torticollis,  when  the  process 
is  located  in  the  muscles  of  the  neck ;  pleurodynia  when  in  the  intercostal 
muscles ;  lumbago  when  in  the  lumbar  muscles ;  cephalodynia  when  in 
the  muscles  of  the  head ;  scapulodynia  and  omodynia  when  in  the  mus- 
cles of  the  shoulder. 

The  disease  may  be  acute  or  chronic,  the  acute  cases  recovering  in 
a  few  days.  The  chronic  cases  may  persist  for  weeks,  often  leading  to 
increase  in  the  connective  tissue,  producing  muscular  stiffness  and  con- 
tractures. 

Diagnosis. — The  diagnosis  is  to  be  made  from  pleurisy  by  the  absence 
of  physical  signs  and  by  the  pain  and  muscular  tenderness.  It  is  distin- 
guished also  from  neuritis,  in  which  the  tenderness  is  along  the  course  of 
the  nerves  and  in  which  massage  is  not  efficient. 

Treatment. — Drugs  are  of  less  use  than  hot  air  and  massage.  Heat 
may  be  apphed  by  means  of  a  hot  flat-iron  rubbed  on  the  affected  part 
protected  by  a  piece  of  thick  flannel.  Massage  is  especially  to  be  recom- 
mended. Electricity  is  of  service  in  chronic  cases.  Phenacetine  and  the 
salicylates  are  the  drugs  which  are  indicated ;  they  should  be  used  with 
caution  if  they  seem  to  benefit  the  especial  case,  and  should  not  be  em- 
ployed as  a  routine  treatment.     The  lithia  waters  should  be  given  freely. 

The  following  case  is  illustrative  of  acute  torticollis  dependent  upon 
acute  rheumatic  fever : 

The  boy  was  five  years  old.  Since  he  was  three  years  old  he  had  been  subject 
to  attacks  of  torticollis,  apparently  of  rheumatic  origin.  He  was  brought  into  the  hos- 
pital in  one  of  these  attacks.  His  temperature  was  somewhat  raised,  and  he  had  a 
slight  loss  of  appetite,  but  otherwise  was  perfectly  well,  and  did  not  suffer  any  pain 
except  Avhen  his  neck  was  touched.  The  head  was  drawn  rigidly  back.  These 
.paroxysmal  attacks  usually  lasted  two  or  three  days,  when  they  passed  off  as  sud- 
denly as  they  came.     The  last  attack  which  he  had  was  one  year  before. 

On  the  following  day  the  stiffness  and  the  pain  in  the  neck  passed  off,  and  the  head 
resumed  its  normal  position.  Various  drugs  had  been  given  in  these  attacks,  but  none 
with  any  especial  benefit  except  salicylate  of  sodium,  which  seemed  to  control  the  pain. 

We  have  also  had  under  our  care  a  little  boy,  about  four  years  of  age,  who  was 
attacked  with  fever,  pain  in  the  region  of  the  spine,  and  spasm  along  the  entire  length 
of  the  spinal  column.  There  was  no  pain  or  tenderness  anywhere  except  over  the  verte- 
bral column,  and  these  symptoms  were  not  so  marked  in  the  cervical  region  as  lower 
down.  The  child  had  no  mental  disturbance,  but  for  a  number  of  days  was  in  a  con- 
dition of  continued  opisthotonos  from  the  hips  upward,  so  that  he  had  to  be  kept  in  a 
reclining  chair  with  pillows  under  his  arched  back.  The  normal  functions  of  the 
bladder  and  intestine  were  not  interfered  with.  The  pulse  v»^as  rapid,  the  temperature 
was  moderately  raised,  and  the  respirations  were  normal.  The  appetite  was  lessened. 
He  remained  in  this  condition  for  about  a  week,  when  the  spasm  of  the  back  began  to 
disappear.  The  muscles  relaxed  for  a  short  time  and  then  stiffened  again.  Finally 
complete  relaxation  took  place,  and  the  child  recovered  entirely.  The  attack  was  acute 
in  its  onset,  and  did  not  follow  any  injury.  The  treatment  was  bromide  of  potassium, 
0.3  gramme  (5  grains)  three  or  four  times  in  the  twenty-four  hours. 


UNCLASSIFIED   DISEASES. 
Fig.  212. 


1027 


Acute  rheumatic  torticollis.    Fifth  dav  of  attack. 


ATROPHIO  AND  EnTPERTROPHIC  DISEASES  OF  THE  JOINTS. 

Although  a  large  amount  of  Avork  has  been  and  is  being  done  in  con- 
nection with  diseases  of  the  joints  in  children,  the  whole  subject  is  still 
in  the  process  of  reconstruction  so  far  as  eliology  and  classification  is 
concerned.  As  in  other  diseases,  such  as  of  the  mouth  and  of  the  gastro- 
enteric tract,  various  names  have  so  long  been  used  to  represent  the  same 
disease,  and  various  diseases  have  so  often  appeared  under  the  same 
name,  that  much  confusion  has  necessarily  resulted,  and  the  work  of 
excellent  investigators  has  thus  been  often  invalidated. 

It  would  be  better  to  discard  all  the  unmeaning  names  Avere  it  not 
that  they  are  so  generally  used  that  they  must  still  be  recognized  as 
having  a  place  in  nomenclature,  at  the  same  time  we  can  explain  wherein 
they  are  lacking  and  substitute  for  them  such  provisional  names  as  express 
our  present  knowledge  of  the  subject.  Inthis  sense  we  should  look  upon 
as  misleading-,  in  connection  with  joint  affections  in  children,  such  head- 
ings as  rheumatoid  disease.  Still's  disease,  arthritis  deformans,  arthritis 
of  infants,  and  a  number  of  others.  We  should  also  be  careful  to  under- 
stand that  the  term  infectious  arthritis  should  be  used  as  representing 
quite  a  large  class  of  infections  of  the  joints  and  not  any  one  specific 
infection. 


1028  PEDIATRICS. 

The  question  which  has  arisen,  and  which  is  still  not  absolutely  set- 
tled, is,  whether  a  certain  class  of  cases,  in'  which  the  symptoms  are  those 
of  a  slowly  developing,  progressive  disease  affecting  the  joints  or  their 
immediate  neighborhood,  represents  a  number  of  types  of  the  same  disease 
sometimes  called  by  such  names  as  rheumatoid  and  arthritis  deformans, 
or  whether  this  class  represents  separate  diseases.  Our  knowledge  of  the 
etiology  of  these  cases  is  practically  7iiL  The  post-mortem  findings  in  all 
these  chronic  types  have  necessarily  been  misleading  and  unsatisfactory, 
as  in  most  cases  it  is  only  the  terminal  pathologic  process  which  can  be 
studied,  and  these  terminal  processes  might  well  simulate  each  other, 
although  differing  markedly  in  their  early  lesions. 

A  careful  study  of  the  symptoms  and  physical  condition  of  the  parts 
affected,  combined  with  the  evidence  of  X-rays  from  the  beginning  and 
following  the  progress  of  the  especial  case,  has  given  the  most  valuable 
information  regarding  these  conditions  and  leads  us  to  believe  that  we  are 
dealing  with  different  processes  rather  than  with  different  phases  of  the 
same  process. 

Although  this  class  of  cases  is  at  times  met  with  in  children,  it  is 
extremely  rare  and  should  be  studied  from  works  devoted  to  adults,  and 
to  orthopaedics  rather  than  to  pediatrics ;  it  will,  therefore,  be  dealt  with 
briefly  and  with  intention  of  showing  how  the  treatment  differs  in  the  two 
chief  types.  In  this  connection  it  is  well  to  state,  merely  because  the 
necessity  of  a  differential  diagnosis  may  possibly  arise,  that  chronio  gout 
may  occur  in  childhood  ;  also  that  what  has  been  called  so  universally  m^/ows 
arthritis  is  in  children  a  secondary  condition  and  it  need  not  be  con- 
sidered. The  remaining  types  of  slow,  progressive  deformities  of  the 
joints  have  been  extensively  studied  in  England  and  in  America  with  the 
result  that  practically  they  are  narrowed  down  to  the  two  chief  types 
referred  to  above.  The  evidence  is  in  favor  of  their  being  two  diseases 
leather  than  two  types  of  the  same  disease.  Whatever  names  may  be 
used  in  the  future,  the  condition  in  one  case  is  essentially  one  of  atrophy 
and  in  the  other  of  hypertrophy.  The  atrophic  cases  have  been  desig- 
nated by  such  names  as  rheumatoid  disease  and  arthritis  deformans. 

The  cause  of  the  disease  is  unknown  ;  it  has  been  suggested  that  it  is 
of  a  trophic  nature.  All  the  joints  may  be  affected  slowly  and  progres- 
sively, but  the  fingers  are  usually  affected  early.  There  is  swelling  of  the 
soft  tissues  about  the  joints,  due  to  synovial  fluid,  with  subsequent 
atrophy  of  the  bony  and  cartilaginous  parts  of  the  joint.  The  diagnosis 
is  made  chiefly  by  means  of  the  X-ray.  The  treatment  is  essentially  to 
increase  the  metabolism  by  massage,  fresh  air,  good  food,  and  tonics. 
When  this  can  be  done  the  disease  is  often  arrested  and  its  severity  miti- 
gated, but  it  usually  goes  on  for  years.  We  have  had  under  our  care  a 
girl  of  eleven  years  with  this  atrophic  form  of  disease. 

The  hypertrophic  cases  are  those  which  have  usually  been  designated 
by  such  names  as  osteo-arthritis,  chronic  rheumatic  arthritis,  and  arthritis 


UNCLASSIFIED   DISEASES.  1029 

deformans.  The  cause  is  unknown.  It  may  be  a  local  or  general  process 
characterized  by  swelling  of  the  joints,  with  hypertrophic  changes  in  the 
bones  and  cartilages  of  the  joint. 

Heberden's  nodes,  to  be  distinguished  from  the  freely  moving  urate  of 
soda  deposits  of  gout,  may  occur  in  the  finger-joints. 

Atrophy  of  the  surrounding  soft  tissue  as  an  end  result  of  ankylosis 
of  the  joint  may  occur.  The  diagnosis  is  made  chiefly  by  the  X-ray. 
The  treatment  is  fixation  in  the  active  stage  and,  later,  orthopaedic. 

INFECTIOUS   ARTHRrriS. 

The  great  majority  of  cases  in  which  the  joints  are  affected  in  children 
is  now  known  to  arise  from  infection.  This  infection  is  due  to  the  pres- 
ence in  the  body  of  one  of  the  specific  organisms,  or  group  of  organisms, 
and  the  affection  of  the  joints  in  most  cases  occurs  in  the  course  of  the 
general  specific  disease.  The  primary  focus  of  infection  may  be  in  any 
part  of  the  body,  as  the  tonsil  or  the  ear.  The  arthritis  may  be  due  to 
the  presence  of  the  specific  organism  in  the  joints  or  to  the  actions  of  its 
toxins  alone.  In  the  former  case  the  local  process  is  more  severe.  It  is 
thus  seen  that  under  the  general  term  infectious  arthritis  should  be  in- 
cluded a  very  large  number  of  diseases. 

The  character  of  the  joint  lesions  depends  upon  the  special  organism 
present,  and  while  in  certain  instances,  such  as  infection  from  the  tubercle 
bacillus  and  in  syphilis,  the  anatomical  conditions  can  often  be  recognized, 
yet  in  most  cases  the  diagnosis  is  made  by  the  occurrence  of  the  arthritis 
in  the  course  of  one  of  the  specific  infections,  such  as  rheumatic  fever, 
gonorrhoea,  scarlet  fever  and  typhoid  fever.  The  diagnosis,  symptoma- 
tology, and  treatment  of  these  cases  of  joint  affections  has  been  described 
under  the  especial  diseases  in  which  they  occur. 

Infectious  arthritis  may  be  the  result  of  any  of  the  infections  or  pus  pro- 
ducing organisms.  The  severity  of  the  attack  depends  not  only  upon  the 
special  organism,  but  upon  its  virulence,  whether  it  is  actually  present  in  the 
joint,  and  upon  the  idiosyncrasy  of  the  individual  child.  Such  organisms  as 
thepneumococcus,  streptococcus,  staphylococcus,  influenza  bacillus,  bacillus 
dysenterise,  and  many  others,  such  as  those  connected  with  erysipelas, 
glanders,  and  cerebro-spinal  meningitis,  may  produce  an  arthritis.  We 
have  not  as  yet,  in  quite  a  large  number  of  cases,  determined  the  especial 
pathology  and  symptoms  belonging  to  the  specific  infecting  organism. 

It  is  this  group  of  cases  in  which  Still  has  done  such  excellent  pioneer 
work  and  his  description  of  the  symptom  complex  representing  them  is 
of  much  value.  We  should,  however,  recognize  that  there  is  no  such 
disease  as  "  Still's  disease,"  but  that  a  number  of  infections  probably  pro- 
duce the  group  of  symptoms  which  has  been  called  by  his  name  but 
which  should  properly  be  referred  to  as  infectious  arthritis.  Looking  at 
the  subject  from  this  point  of  view  it  is  easily  understood  that  all  of  the 
sympioms  described  by  Still  need  not  be  especially  marked  in  every  case 


1030  PEDIATRICS. 

and  different  symptoms  of  infection  may  arise  in  certain  cases  according 
to  the  nature  of  the  infection  or  its  virulence.  So  that  no  fixed  symptoma- 
tology "will  cover  all  cases.  The  spleen  is  more  apt  to  be  enlarged  in 
children  than  in  adults  owing  probably  to  its  greater  reaction  to  toxaemia 
in  early  life.  The  symptoms  are  those  of  infection  and  may  begin  acutely 
with  fever  and  chills  or  insidiously  with  stiffness  and  gradual  enlargement 
of  the  joints  which  assume  an  elastic  fusiform  shape  but  without  bony 
change. 

Still's  description  of  the  various  phases  of  this  group  of  infections  in 
children  covers  the  ground  as  Avell  as  can  be  done  until  we  have  a  more 
precise  knowledge  of  the  characteristic  manifestations  of  the  individual 
infecting  organism. 

It  is  as  follows  : 

The  joints  earliest  affected  are  those  of  the  hands,  wrists  and  cervical  spine,  the 
ankles,  elbows,  fingers  and  other  joints  being  subsequently  involved.  The  affection  of 
the  joints  is  symmetrical.  The  enlargement  looks  and  feels  more  like  a  general  thick- 
ening of  the  tissues  around  the  bones  than  a  bony  enlargement,  and  is  correspondingly 
smooth  and  fusiform  without  bony  irregularity.  There  is  no  osteophytic  growth  even 
after  years.  There  is  never  bony  grating.  There  is  no  tenderness  or  redness  except  in 
very  acute  cases.  Pain  is  absent  as  a  rule,  except  on  motion,  when  it  may  be  present. 
There  is  always  limitation  of  motion.  There  is  no  tendency  to  suppuration  or  bony- 
anchylosis.  The  muscles  which  move  the  diseased  joints  show  early  and  marked 
wasting  without  change  in  the  electrical  reactions.  The  most  distinctive  feature  is  the 
enlargement  of  the  glands,  which  is  general  but  affects  primarily  and  chiefly  those 
related  to  the  affected  joints.  The  glands  are  separate,  hard,  not  tender,  and  show  no 
tendency  to  break  down.  Their  size  varies  with  the  acuteness  of  the  symptoms  in  the 
joints.  Enlargement  of  the  spleen  is  almost  always  present,  the  amount  of  enlargement 
var^'ing  directly  with  that  of  the  glands  and  the  acuteness  of  the  joint  symptoms. 
There  is  generally  a  moderate  diminution  in  the  number  of  red  corpuscles,  often 
associated  with  a  disproportionate  diminution  in  the  amount  of  hsemoglobin.  The 
pyrexial  attacks  are  not  usually  associated  with  any  clinically  demonstrable  exacerbation 
of  the  joint  trouble.  The  urine  shows  nothing  important.  Slight  exophthalmos  is 
sometimes  present.  The  heart  shows  no  evidence  of  valvular  disease,  although 
adherent  pericardium  has  been  found  several  times  at  autopsy.  The  course  is  slow. 
Improvement  make  take  place  for  a  time  under  treatment  or.  spontaneously.  The 
disease  soon  progresses  again,  however,  until  a  condition  of  general  joint  disease  is 
reached  which  seems  to  he  permanently  stationary.  It  is  not  fatal,  the  few  recorded 
deaths  having  been  due  to  complications.  Pathologically,  the  joints  show  marked 
thickening  of  the  capsule  and  of  the  connective  tissues  just  outside  it.  There  is  also 
thickening  and  vascularization  of  the  synovial  membrane.  Fibrous  adhesions  are 
sometimes  present.  The  cartilages  may  show  pitting  at  their  margins  from  the 
pressure  of  little  processes  of  the  thickened  synovial  membrane,  but  are  otherwise 
healthy. 

The  X-ray  is  of  great  importance  in  tlie  differential  diagnosis. 

Treatment.— The  serum  treatment  has  not  yet  been  sufficiently 
successful  to  be  recommended  at  present.  The  treatment  of  each  case 
must  be  symptomatic  and  directed  in  the  beginning  to  the  acute  symp- 
toms.    It  is  well  to  bear  in  mind  that  the  salicvlates  are  not  indicated  and 


UNCLASSIFIED   DISEASES.  1031 

may  do  harm  by  their  depressing  effects.     The  later  treatment  is  to  build 
up  the  general  health  with  fresh  air,  good  food,  and  tonics. 

EPIPHYSEAL    HYPERuSEMIA    (Growing  Pains). 

During  the  period  of  middle  childhood  children  at  times  complain  of 
pains  in  their  limbs,  especially  the  legs.  In  some  cases  these  pains  are 
probably  closely  associated  with  muscular  rheumatism,  since  they  may 
also  occur  in  the  joints. 

These  indefinite  pains  are  usually  spoken  of  as  '•'•  groioing  pains^''''  but 
should  be  distinguished  from  rheumatism  by  their  slight  and  evanescent 
character  and  by  their  lasting  perhaps  only  for"  a  few  minutes  or  hours. 
They  are  supposed  to  be  induced  by  fatigue  and  to  be  in  some  way  con- 
nected with  hypergemia  of  the  epiphyses  in  the  process  of  their  develop- 
ment. 

DIABETES    INSIPIDUS. 

Diabetes  insipidus  is  a  disease  characterized  by  the  passage  of  large 
quantities  of  urine  of  very  low  specific  gravity,  free  from  sugar  and  other 
abnormal  elements,  and  often  with  a  considerable  increase  in  the  total 
amount  of  sohds. 

Etiology, — The  cause  of  the  disease  is  not  known.  The  most  plausible 
theory  at  present  is  that  the  disease  is  due  to  a  derangement  of  the  nerv- 
ous mechanism  controlling  the  fluid  balances  of  the  body.  Experiments 
seem  to  show  that  injury  to  the  centre  in  the  medulla  for  fluid  regulation 
will  cause  polyuria.  It  is  possible  that  in  some  cases  there  may  be  a  con- 
genital absence  of  such  a  centre,  in  others  that  its  function  may  be 
impaired  by  some  injury  to  the  head.  It  has  also  been  explained  as  being 
in  the  nature  of  a  neurosis,  causing  a  vasomotor  disturbance  of  the  renal 
vessels  with  continuous  congestion  of  the  kidney.  In  a  series  of  eighty- 
five  cases  collected  by  Strauss,  nine  Avere  under  five  years,  and  twelve 
between  five  and  ten  years.  In  seventy  cases  reported  by  Roberts, 
twenty-two  occurred  before  ten  years.  It  may  be  congenital  or  begin  in 
infancy,  but  is  an  exceedingly  rare  disease.  In  certain  cases  there  is  a 
strong  hereditary  tendency.  It  has  been  recorded  in  the  members  of 
four  generations  of  one  family  (Weil). 

Pathological  Anatomy. — Enlargement  and  congestion  of  the  kidneys, 
hypertrophy  of  the  bladder,  dilatation  of  the  ureters  and  pelves  of  the 
kidney,  and  inconstant  lesions  of  the  nervous  system  have  been  noted. 

Symptoms. — The  symptoms  are  directed  especially  to  the  urine,  which 
is  passed  in  very  large  quantities  ;  in  one  case  of  Trousseau's,  in  an  adult, 
amounting  to  twenty-eight  quarts  a  day.  There  is  a  very  low  specific 
o-ravity,  varying  from  1001  to  1005  or  1007.  Glucose  is  never  present,  but 
inosite  (muscle-sugar)  has  at  times  been  noted.  Albumin  and  casts  are  of 
only  rare  occurrence.  The  total  solids  are  normal  or  in  many  cases  greatly 
increased. 

Intense  thirst,  a  dry  skin,  disturbance  in  the  surface  circulation,  and 


1032  PEDIATRICS. 

general  nervous  symptoms  are  present,  but  emaciation  is  not  apt  to  occur 
as  in  diabetes  mellitus.  The  appetite  is  good.  Often  the  general  health 
is  not  interfered  "with,  and  the  disease  may  last  for  a  period  of  years. 

Diagnosis. — The  condition  is  to  be  distinguished  from  nervous  or  hys- 
terical polyuria,  which  is  of  temporary  duration  and  is  associated  with 
other  hysterical  symptoms. 

It  is  differentiated  from  diabetes  mellitus  by  the  absence  in  the  urine 
of  glucose  or  grape-sugar. 

Chronic  interstitial  nephritis  may  be  excluded  from  the  diagnosis  by 
the  presence  of  albumin  and  casts  and  the  low  percentage  of  solids  elim- 
inated, together  with  the  clinical  symptom  of  chronic  nephritis. 

Prognosis. — Occasionally  spontaneous  recovery  may  take  place,  but 
oftener  the  disease  is  likely  to  remain  chronic  and  the  child  to  die  of  some 
intercurrent  affection.  Cases  in  which  recovery  took  place  after  acute 
attacks  of  fever  have  been  reported. 

Treatment. — A  nitrogenous  diet  with  small  amounts  of  carbohydrates 
and  only  a  moderate  restriction  of  fluids  are  indicated.  Drugs  do  not 
control  the  disease,  although  many  have  been  recommended,  the  most 
prominent  of  these  being  belladonna  in  increasing  doses  up  to  its  physio- 
logical limits,  and  opium,  continued  for  many  months.  Arsenic  and  the 
bromides  may  also  be  tried,  but  their  beneficial  action  is  doubtful. 

DIABETES  MELLITUS. 

Diabetes  mellitus  is  a  disease  characterized  by  the  excretion  in  the 
urine  of  glucose  or  grape-sugar  in  considerable  quantities  and  for  a  long 
period.  It  is  sometimes  acute,  but  is  generally  chronic.  It  is  to  be  dis- 
tinguished from  the  condition  known  as  tempora.n^  glycosuria^  in  which 
sugar  is  present  in  the  urine  for  a  short  time  only,  as  after  certain  acute 
infectious  diseases,  injuries  to  the  head,  or  from  absorption  of  some  toxic 
/--'  substance.  There  is  still  another  variety  of  glycosuria  which  is  spoken 
of  as  temporary  alimentary  glycosuria.  In  this  form  sugar  appears  in  the 
urine  after  the  ingestion  of  large  quantities  of  saccharine  foods,  and  dis- 
appears at  once  upon  reducing  the  sugar  in  the  diet. 

Etiology. — Diabetes  mellitus  may  occur  in  infancy  or  at  any  period 
of  childhood.  It  is  ver}"  common  among  the  Jews,  and  is  infrequent 
among  the  negroes. 

It  occurs  more  frequently  in  girls  than  in  boys.  In  Stern's  analysis 
of  one  hundred  and  seventeen  cases  in  children,  six  were  under  one  year 
of  age. 

In  many  cases  an  hereditary  influence  seems  to  be  a  factor  in  the 
etiology ;  in  others  a  severe  nervous  shock,  such  as  may  come  from  sud- 
den fright  or  great  grief,  may  be  an  exciting  cause.  Trousseau  states  that 
the  children  of  tubercular  parents  are  particularly  susceptible  to  diabetes. 
Injuries  to  the  head,  especially  if  the  floor  of  the  fourth  ventricle  is  hi- 
volved,  may  cause  the  appearance  of  sugar  in  the  urine.     Occasionally 


UKCLASSIFIED   DISEASES.  1033 

temporary  glycosuria  may  arise  from  the  administration  of  antitoxin, 
and  it  may  appear  shortly  before  death  in  cases  of  chronic  nephritis  and 
subacute  glomerular  nephritis. 

PancreatiG  diabetes  follows  the  removal  of  the  pancreas  in  dogs,  and 
lesions  in  the  pancreas  are  found  in  about  half  of  the  cases  of  diabetes 
mellitus ;  the  appearance  of  sugar  in  the  urine  in  these  cases  is  supposed 
to  be  due  to  the  absence  of  the  glycolytic  ferment  in  the  pancreatic  juice. 

Phloridzin  and  a  few  other  substances  may  cause  diabetes  mellitus  by 
destroying  the  power  of  the  renal  epithelium  to  keep  back  the  sugar. 

Faulty  metabolism  and  defective  assimilation  of  the  glucose  probably 
underlie  most  cases  of  diabetes,  but  much  is  to  be  learned  as  to  the  real 
nature  of  the  disease. 

Pathological  Axatomy. — Lesions  in  the  medulla  from  tumors  or  scle- 
roses have  been  found,  and  glycogen  has  been  foLmd  in  the  spinal  cord. 
There  may  be  a  secondary  multiple  neuritis.  The  blood  may  contain  as 
much  as  0.4  per  cent,  of  sugar  instead  of  the  normal  0.15  per  cent.  The 
plasma  is  fatty  and  the  polynuclear  leucocytes  contain  glycogen.  Tuber- 
culosis of  the  lungs  is  not  uncommon,  and  may  follow  an  acute  broncho- 
or  pneumococcus  lobar  pneumonia.  The  liver  is  enlarged  and  fatty. 
Lesions  of  the  pancreas,  especially  of  the  islands  of  Langerhaus,  generally 
atrophy,  are  ]3resent  in  nearly  fifty  per  cent,  of  the  cases.  The  kidneys 
usually  show  evidence  of  diffuse  nephritis  with  fatty  degeneration. 

Symptoms. — The  symptoms  in  the  temporary  form  of  diabetes  may  be 
slight,  and  the  sugar  is  discovered  only  in  the  routine  examination  of  the 
urine.  There  may  be  an  increased  flow  of  urine  and  a  craving  for  sweet 
articles  of  diet.  The  appetite  is  good.  The  thirst  may  be  increased. 
Indigestion  is  not  uncommon. 

In  true  diabetes  the  symptoms  are  much  more  severe.  Great  thirst, 
excessive  appetite,  and  polyuria  are  the  striking  symptoms.  There  is  pro- 
gressive and  extreme  emaciation,  the  skin  is  harsh  and  dry ;  sweating  is 
rare.  Constipation  is  usually  present.  The  flow  of  saliva  is  abundant. 
The  genitals  are  at  times  irritated  by  the  urine. 

Urine. — The  quantity  of  urine  is  greatly  increased,  generally  averaging 
between  3000  to  5000  c.c.  (100  to  166  ounces),  although  it  may  be  much 
more  or  be  less  than  normal.  The  urine  is  pale,  strongly  acid,  and  of 
hio-h  specific  gravity,  the  degree  depending  upon  the  amount  of  sugar 
present.  The  solids  are  relatively  diminished  but  absolutely  increased  in 
amount.  Glucose  or  sugar  is  always  present,  and  varies  from  a  mere 
trace  to  8,  10,  or  12  per  cent.,  and  the  total  quantity  m  twenty-four  hours 
varies  from  20  to  60  grammes  (f  to  2  ounces),  often  amounting  to  sev- 
eral hundred  grammes.  There  is  usually  the  slightest  possible  trace  of 
albumm  and  a  few  casts,  indicative  of  a  mild,  acute  degeneration  of  the 
kidneys. 

Diabetic  Coma. — Diabetes  mellitus  frequently  ends  in  coma,  this  pre- 
sumably being  brought  about  by  some  toxic  substance  in  the  blood.    This 


1034  PEDIATRICS. 

complication  is  especially  common  in  children.  It  is  at  times  precipitated 
by  sudden  changes  in  diet,  especially  when  the  patient  is  put  upon  a  rigid, 
nitrogenous  diet,  but  it  may  also  follow  many  other  conditions,  such  as 
intercurrent  acute  diseases  and  operations. 

Acetone  and  diacetic  acid  and  B-oxybutyric  acid  are  found  in  the  urine 
in  advanced  cases  of  diabetes,  and  are  always  of  serious  prognosis,  as  they 
indicate  a  threatened  state  of  coma,  but  they  may  be  present  for  months 
before  any  symptoms  of  coma  appear,  and  may  even  disappear  as  the 
patient  improves  under  treatment.  Acetone  and  diacetic  acid  are  prob- 
ably rarely,  if  ever,  present  in  cases  of  temporary  glycosuria. 

The  advent  of  coma  may  be  suspected  by  the  appearance  of  mental 
apathy,  nausea,  vomitmg,  and  epigastric  pain.  The  breath  has  a  peculiar 
odor  of  acetone.  Convulsions  rarely  occur,  which  is  a  point  of  con- 
siderable value  in  excluding  a  coma  due  to  ursemia.  Bremer's  blood-test 
T\ith  methylene-blue  or  congo-red  \vi\\  also  aid  in  determining  the  nature 
of  the  coma,  as  a  positive  reaction  will  almost  always  be  obtained,  even 
in  the  early  stages  of  diabetes  mellitus. 

Complications. — Boils,  furuncles,  eczema,  and  prurigo  are  common 
complications.  Gangrene  may  occur.  Pneumococcus  lobar  pneumonia, 
broncho-pneumonia,  and  especially  tuberculosis  of  the  lungs,  are  likely  to 
occur  and  prove  fatal. 

Peripheral  neuritis  Avith  pain  and  paralysis  may  occur,  sometimes 
with  symptoms  suggestive  of  tabes.  The  disease  may  be  manifested  by 
paralysis,  either  the  arms  or  legs  being  affected,  the  form  being  diplegic. 
Absence  of  the  knee-jerk  is  not  uncommon,  and  is  probably  due  to 
neuritis.  Mental  depression  or  extreme  restlessness  or  nen'ousness  often 
develops. 

Cataract,  retinitis,  sudden  amaurosis,  ocular  paralysis,  and  atrophy  of 
the  optic  nerves  occasionally  occur.  Otitis  media  or  a  mastoiditis  may 
/--  appear  suddenly.  (Edema  is  a  common  symptom,  and  does  not  always 
depend  on  disease  of  the  heart  or  kidney. 

Diagnosis. — It  is  important  to  distinguish  between  diabetes  mellitus 
and  temporary  glycosuria.  This  is  sometmies  difficult.  In  the  former, 
however,  sugar  is  present  in  every  specimen  of  urine  passed,  irrespective 
of  the  time  of  day.  In  temporary  alimentary  glycosuria  the  urine  in  the 
early  mornmg,  after  ten  or  tAvelve  hours  of  fastmg,  is  generally  free  from 
sugar,  or  only  traces  are  present,  whereas  after  a  meal  considerable 
quantities  of  sugar  are  elimina+ed.  A  rigid  diet,  free  from  carbohydrates, 
will  also  help  to  make  the  distinction  clear,  as  the  quantity  of  sugar  in 
true  diabetes  mellitus  is  reduced  only  A\dth  difficulty  and  often  cannot  be 
markedly  influenced. 

From  other  forms  of  pohnjria  the  diagnosis  is  made  clear  by  the 
presence  of  sugar  as  determhied  by  Fehling's  test. 

Bremer's  blood-test  with  congo-red  is  a  valuable  aid  in  differentiating 
true  diabetes  mellitus  from  phloridzin  diabetes. 


UNCLASSIFIED   DISEASES.  1035 

Prognosis. — The  disease  runs  a  much  more  rapid  course  in  children 
than  in  adults.  In  Sterns'  one  hundred  and  seventeen  cases  the  shortest 
duration  was  two  days.  In  seven  cases  death  took  place  within  a  month. 
He  mentions  one  case  of  a  child  whose  urine  contained  sugar  at  birth, 
and  who  recovered  in  eight  months.  In  children  the  disease  is  almost 
universally  fatal,  but  Sterns,  in  a  series  of  seventy-seven  cases  in  children, 
found  that  fourteen  recovered,  and  in  one  hundred  and  eight  cases,  also 
children,  reported  by  Wegeli,  only  sixty-four  terminated  fatally. 

The  younger  the  child  the  more  grave  is  the  prognosis. 

Treatment. — The  treatment  of  diabetes  mellitus  consists  practically  in 
the  regulation  of  the  diet,  the  endeavor  being  to  limit  the  ingestion  of 
carbohydrates.  This  is  especially  important  in  prophylaxis.  The  diet 
should  consist,  so  far  as  possible,  of  meat,  fish,  eggs,  green  vegetables, 
salads,  and  nuts.  Too  great  a  quantity  of  meat  should  be  avoided,  as 
excessive  nitrogenous  food  as  Avell  as  carbohydrates  will  increase  the 
percentage  of  sugar  in  the  urine. 

It  is  well  to  test  the  patient's  capacity  to  assimilate  sugar  by  cjuanti- 
tating  the  sugar  passed  in  twenty-four  hours  when  on  ordinary  diet,  and 
then  to  institute  a  strict  diet  for  several  days,  the  sugar  being  estimated 
daily.  The  results  will  give  us  indications  as  to  whether  to  push  the  re- 
stricted diet  or  to  allow  more  freedom  in  the  choice  of  foods.  When 
coma  is  threatened,  or  when  the  reaction  for  diacetic  acid  with  ferric 
chloride  is  positive,  carbohydrates  should  be  added  to  the  diet  for  a  time. 

If  under  a  strict  diet  the  sugar  disappears,  the  diet  can  gradually  and 
cautiously  be  increased,  but  at  intervals  of  a  few  months  diabetics  should 
return  to  their  restricted  diet  for  a  few  weeks  as  a  matter  of  precaution 
and  to  increase  their  power  of  assimilation  of  the  carbohydrates. 

Carbohydrates  are  best  tolerated  if  given  continuously  in  one  form. 
Lactose  is  as  well  borne  as  any  other  carbohydrate,  and  in  infants  a  milk 
diet  is  therefore  the  safest  method  of  treatment.  The  use  of  sodium 
bicarbonate  in  large  doses  by  mouth  or  rectum  is  indicated  for  the  treat- 
ment of  threatened  coma. 

The  following  articles  represent  as  varied  a  diet  list  for  diabetics  as  is 
compatible  with  conservative  treatment ;  oxtail  soup,  bouillon,  and  clear 
soups  made  from  meats  ;  lemonade,  chocolate,  and  cocoa,  with  saccharin 
for  sweetening ;  soda-water  and  charged  waters. 

Fresh  fish  of  all  sorts,  with  oysters  in  season,  poultry,  game,  e^s, 
butter,  buttermilk,  and  cream  cheese,  lettuce,  tomatoes,  spinach,  chicory, 
sorrel,  radishes,  asparagus,  watercress,  cucumbers,  celery,  and  endiA'es  are 
permissible. 

Of  the  fruits,  lemons,  oranges,  currants,  plums,  cherries,  pears,  apples, 
melons,  raspberries,  and  strawberries  may  be  taken  in  moderation  ii  a 
strict  diet  is  not  being  adhered  to.  Nuts  may  be  given  if  they  do  not 
disturb  digestion. 

Among  the  articles  especially  to  be  avoided  are  thick  soups,  liver,  all 


1036  PEDIATRICS. 

forms  of  bread,  and  all  dishes  prepared  with  flour  or  sugar.  Vegetables 
growing  under  ground  are  to  be  avoided.  Beers,  wines,  and  alcoholic 
drinks  should  not  be  used.  Most  of  the  gluten  breads  and  diabetic  flours 
in  the  markets  are  adulterated  with  flour,  and  cannot  be  relied  upon. 

But  little  is  to  be  expected  in  the  treatment  of  diabetes  from  the  use 
of  drugs,  except  so  far  as  to  allay  symptoms.  Opium,  usually  given  in  the 
form  of  codeia,  is  quite  generally  used,  but  we  have  not  ourselves  seen 
striking  results  from  its  administration. 

HYPERTROPHIC  PULMONARY  OSTEO-ARTHROPATHY. 
Hypertrophic  pulmonary  osteo-arthropathy  is  a  condition  character- 
ized by  enlargement  of  the  hands  and  feet  and  the  ends  of  the  long 
bones.  The  terminal  phalanges  are  increased  both  in  the  transverse^  and 
longitudinal  curves,  and  the  nails  show  a  tendency  to  be  curved  over  the 
ends  of  the  phalanges.  Unlike  acromegaly,  the  bones  of  the  skull  and 
face  are  not  involved.  The  condition  was  first  described  by  Bamberger, 
and  the  name  was  given  to  it  by  Marie.  Two  distinct  sets  of  changes  may 
be  noted,  in  the  bone  and  in  the  soft  parts.  The  chronic  inflammatory 
process  causes  a  rarification  of  the  central  cancellous  bone  and  a  produc- 
tion of  layers  of  osteophytic  growth  at  the  periphery.  The  thickening 
of  the  terminal  phalanges  is  due  chiefly  to  an  increase  in  the  soft  parts. 

Fig.  213. 


Chronic  pulmonary  osteo-artliropath}-  in  a  boy  'i%  years  of  age.  Total  chrome  consolidation  of  left 
lung  from  influenza  of  several  months  duration.  Radiographs  of  tlae  fingers  aud  toes  showed  the  termi- 
nal phalanges  as  well  as  the  soft  parts  to  be  both  elongated  and  thickened. 

Various  diseases  may  give  rise  to  this  condition,  such  as  long-continued 
suppuration  and  gangrenous  processes,  tuberculosis  of  the  lung  with 
cavity  formation,  bronchiectasis,  empyema,  pyelonephritis,  and  chronic 
infectious  diarrhoeas.  Another  group  of  diseases  which  are  etiological 
factors  are  certain  infectious  and  chemical  intoxications  such  as  pneu- 
monia, pleurisy,  influenza,  syphilis,  chronic  jaundice  and  alcoholism. 
Congenital  and  chronic  acquired  valvular  diseases  of  the  heart  are 
common  causes.  Finally,  we  see  the  condition  in  malignant  tumors,  such 
as  sarcoma  and  carcinoma  of  various  organs. 


INDEX. 


Abdomen,  at  term,  33 

in  prenaature  infants,  249 
nonnal  development  of,  56 
Abdominal  bands,  93 
Abscess,  cerebral,  972 
of  liver,  839 
of  lung,  707 
peritonsillar,  653 
retropharyngeal,  655 
Acardia,  721 
Acarus  scabiei,  349 
Acetonemia,  778 
Acetonuria,  779 
Achondroplasia    (vide   Chondrodystrophia 

foetalis),  331 
Achorion  Schoenleinii,  354 
Addison's  disease,  924 
Adenitis,  simple  acute,  912 
simple  chronic,  913 

diagnosis  from  Hodgkin's 
disease,  913 
from  new  growths,  914 
from  syphilitic  adenitis,  914 
from  tubercular  adenitis,  913 
Adenoid  growths,  644 
diagnosis,  645 
etiology,  644 
Goodale's  sign  of,  646 
pathological  anatomy,  644 
prognosis,  647 
symptoms,  644 
treatment,  647 
Adrenal  glands,  diseases  of  the,  924 
J]]stivo-autumnal  parasite,  476,  477 
Agenesis  corticalis,  950,  974 
Airing,  100 

Albuminuria,  from  antitoxin,  466 
in  diphtheria,  466 
of  adolescence,  852 
physiological,  852 
Albumin  water,  789  _ 
Alimentary  glycosuria,  1032 
Alkalies,  influence  on  coagulation  of  milk, 
171,  172 
use  of,  190 
Alopecia  areata,  355 
in  syphilis,  518 
Amaurotic  family  idiocy,  950 
Amnesia,  temporary,  960 
Amoeba  coli,  494 

infection  by,  494 
etiology,  494 

pathological  anatomy,  494 
prognosis,  495 
symptoms,  495 
treatment,  495 


Amyloid  degeneration  of  the  heart,  734 
infiltration  of  the  kidney,  865 
liver,  840 
Amylolytic  function  in  premature  infants, 

251 
Amyotrophic  lateral  sclerosis,  1015 
Amyotrophies,  1014 

Anaemia  infantum  pseudo-leukaemica,  898 
Anaemia,  pernicious,  902 
blood  in,  902 
diagnosis,  903 
etiology,  902 
illustrative  case,  904 
pathological  anatomy,  902 
prognosis,  903 
symptoms,  902 
treatment,  904 
urine,  603 
primary,  902 
secondary,  908 
diagnosis,  910 
etiology,  909 
sjonptoms,  909 
prognosis,  910 
treatment,  911 
Anaemia  splenica,  898 
Anencephalia,  276 
Aneurism,  720 

Aneurisms,  intra-cranial,  1002 
Angioma  (vide  Nsevus),  312 
Angio-neurotic  oedema,  375,  965 
Animal  heat  of  premature  infants,  252 

parasites  {vide  Worms),  831 
Anopheles  quadrimaculatus,  475 
Anterior  poliomyelitis,  acute,  981 
Antipyrin,  dose  of,  501 
Antitoxin,  for  immunization  in  diphtheria 
462 
for  treatment  of  diphtheria,  464 
in  cerebro-spinal  meningitis,  433 
in  diphtheria,  464 
technique  of  injection,  466 
Anuria,  851 
Anus,  imperforate,  293 

in  syphilis,  519 
Aorta,  absence  of  the  isthmus  of  the,  720 
narrowing  of  the  isthmus  of  the,  720 
transpositions  of  the,  721 
Aortic  valve,  acquired  diseases  of  the,  743 
congenital  diseases  of  the,  726 
insufficiency,  743 
stenosis,  744 
Aphasia,  temporary',  960 
Aphthaj,  613 
Appendicitis,  826 
chronic,  829 
diagnosis,  830 
etiology,  826 

1037 


1038 


INDEX. 


Appendicitis,  pathological  anatomy,  826 
prognosis,  830 
simple,  827 
symptoms,  827 
treatment,  831 
with  general  suppurative  peritonitis, 

829 
with  peri-appendicular  peritonitis,  828 
Aran-Duchenne  tj'pe  of  progressive  mus- 
cular atrophy,  1014 
Ai-gyll-Robertson  pupil,  1012 
Arrested  psychical  development,  952 
Arteries,  transposition  of  the  large,  726 
Ai-teritis  umbilicalis,  287 
Arthritis  (vide  Joints,  atrophic  and  hyper- 
trophic diseases  of  the) 
clironic  rheumatic,  1028 
deformans,  1028 
infectious,  1029 
of  infants,  acute,  502 
villous,  1028 
Artificial  feeding   (vide  Feeding,   indirect 
substitute),  158 
foods,  229 
Ascaris  lumbricoides,  833 
Auscites    (vide   symptoms   of   the   especial 

disease) 
-Asphyxia  in  the  new-bom,  298 
Aspiration  pneumonia,  691 
-Aspirin,  dose  of,  509 
-Ass's  milk,  161 
-Asthma,  bronchial,  672 
dyspepticum,  969 
false,  673 
Ataxia,  hereditary,  1012 

locomotor,  1012 
Atelectasis,  705 
acquired,  706 
congenital,  705 
Athetosis,  acquired,  999 

congenital,  1000 
Athrepsia,  341 
Athyrea,  916 

Atrophy,  acute  yellow,  of  liver,  838 
infantile,  341 

diagnosis,  343 

from    general    tuberculosis, 

344 
from  starvation,  343 
otiologj^j  341 

illustrative  cases,  346-348 
pathological  anatomy,  342 
primar\%  341 
prognosis,  344 
secondary,  341 
symptoms,  343 
treatment,  344 
muscular  (vide  Muscular  atrophy) 
Atropine,  dose  of,  464 
Auscultation  in  physical  examination,  240 
AjTshire  cow,  162 


Babcock  fat-tester,  212 

Bacillus  lactis  aerogenes. 

Bacillus  of  Eberth,  439 

of  Flexner,  818 

of  Klebs-Loeffler,  451 

of  Pfeiffer,  471 


170 


Bacillus  of  Shiga,  818 

of  tetanus,  489 
Bacteria  in  milk,  166,  178 
Balanitis,  876 

Barley  decoctions,  analysis  of,  168,  184 
as  attenuants,  177 
method  of  making,  184 

jelly,  method  of  making,  184 
Basin  for  bathing  infant,  91 
Bathing,  rules  for,  90 

technique  of,  in  typhoid,  447 
Bed,  infant's,  88 
Bednar's  aphthae,  620 
Belladonna,  tincture  of,  dose  of,  879 
Beri-beri,  1009 

Bicarbonate  of  soda  (vide  Alkalies),  190 
Bile,  at  term,  38 

character  of,  in  infants,  78 
Bile-ducts,  congenital  obliteration  of,  294 

pathological  anatomy,  294 

sjanptoms,  296 

treatment,  296 
Bilian,'  calculi,  840 
Birth-palsies,   973 
Birth-parah'sis,  297 

Bismuth,  effect  on  intestinal  contents,  796 
Bladder,  at  term,  21,  36 

diseases  of  the,  873 

normal  development  of,  57 

reflex  symptoms  of,  971 

tuberculosis  of,  422 
Blood  (vide  also  the  especial  disease) 

amount  at  birth,  881 

at  term,  38 

basophiles  in  the,  884 

chart  showing  proportions  of  leuco- 
cytes in  the,  883 

color  of,  881 

diseases  of  the,  880 

erj^throcji;es  in  the,  882,  887 

hgematoblasts  in  the,  882 

haemoglobin  in  the,  881,  887 

in  abnormal  conditions,  885 

in  infantile  atrophj-,  343 

in  normal  conditions,  880 

in  rhachitis,  325 

iodine  reaction  in  the,  888 

large  mononuclears  in  the,  883 

leucocytes  in  the,  882,  887 

IjTnphocj'ies  in  the,  883 

mast-cells  in  the,  884 

megaloblasts  in  the,  903 

megalocj'ies  in  the,  903 

myelocytes  in  the,  884 

normoblasts  in  the,  903 

origin  of  leucocytes  in  the,  885 

poljmuclear  eosinophiles  in  the,  884 
leucocytes  in  the,  884 

reaction  of  the,  881 

red  corpuscles  in  the,  882-887 

specific  gravity  of  the,  881-887 

transitional  cells  in  the,  883 

white  corpuscles  in  the,  887 
Blood-vessels,  diseases  of  the,  720 

normal  development  of,  55 
Bone-marrow,  at  term,  37 
Bones,  pyaemia  of  the,  502 

in  rhachitis,  314-318 
in  sjTjhihs,  515,  520,  529 
Bow-legs,  105 


INDEX. 


1039 


Brain,  at  term,  29 

in  cerebro-spinal  meningitis,  425 
normal  development  of  the,  46 
syphilis  of  the,  1004 
tuberculosis  of  the,  400 
tumors  of  the,  1001 
Branchial  fistulge,  282 
Brandy  as  a  stimulant,  dose  of,  244 
Breast-milk  {vide  Milk,  human) 
Breast-pump,  113 
Breck  feeder,  260 
Bremer's  blood-test,  1034 
Bretonne  cow,  162 
Bright's  disease  {vide  Nephritis) 
Broadbent's  sign,  766 
Bromide,  doses  of,  931 
Bromoform,  dose  of,  501 
Bronchi,  diseases  of  the,  664 
Bronchial  asthma,  672 
Bronchiolitis  exudativa,  672 
Bronchitis,  acute,  665 
diagnosis,  667 
etiology,  665 

pathological  anatomy,  665 
prognosis,  668 
symptoms,  666 
treatment,  668 
unusual  form  of,  668 
capillary,  697 
chronic,  670 
fibrinous,  671 
Broncho  cele,  914 

Broncho-pneumonia,    acute    {vide    Pneu- 
monia,  acute     broncho-), 
691 
tubercular,  389 
diagnosis,  390 
etiology,  389 
pathological    anatomy, 

389 
prognosis,  390 
symptoms,  389 
treatment,  390 
in  diphtheria,  459 
Brooders,  for  premature  infants,  257 
Broths,  235 

Brown  atrophy  of  the  heart,  734 
Brown  Swiss  cow,  162 
Bruit  de  diable,  908 

de  galop,  458 
Brunner's  glands,  at  term,  35 
Buhl's  disease,  298 
Bulbar  paralysis,  1009 
Bursa  pharyngea,  28 
Butter-milk,  231 

O. 

Cachexia  strumipriva,  916 

Caecum,  normal  development  of,  64 

Calcareous  degeneration  of  the  heart,  734 

Calcium-casein,  171  to  173 

Calculation  of  modifications  according  to 

percentages,  187  to  193 
of  percentages  from  known  mixtures, 

195 
Calomel,  dose  of,  801 
Caloric  value  of  milk  modifications,  201 
Calories,  for  premature  infants,  261 
Caiial  of  Nuck,  hydrocele  of,  292 


Cancrum  oris  {vide  Noma) 

Cane-sugar  in  feeding  of  second  year,  232 

Canker,  613 

Capillary  bronchitis,  697 

Caput  succedaneum,  272 

Cardiac  dilatation  {vide  also  Heart),  732 

hypertrophy,  731 
Caries  of  spine,  paralysis  caused  by,  989 
Carotid  artery  at  term,  32 
Carpet,  in  nursery,  87 
Cascara  sagrada,  dose  of,  800 
Caseinogen  in  cow's  milk,  171 

in  cow's  milk  and  human  milk,  191 
Casselberry's  method  of  feeding,  469 
Castor  oil,  dose  of,  783 
Catalepsy,  958 
Ceiling,  in  nursery,  88 
Cephalhsematoma,  273 
external,  273 
internal,  275 
treatment,  273 
Cephalodynia,  1026 
Cereal  decoctions,  analysis  of,  168 

calculation  of  starch  in,  191 
formulae  for  calculating,  216 
in  feeding  of  second  year,  232 
use  of,  177 

use  of,  in  percentage  feeding,  204 
Cerebral  abscess,  972 

palsies,  infantile,  972 
paralysis,  972 

diagnosis    from    anterior    polio- 
myelitis, 976 
from  caries  of  the  spine,  977 
from  idiocy,  977 
from    obstetrical    paralysis, 

990 
from  rhachitis,  327 
from  syringomyelia,  977 
etiology  of,  973 
extra-uterine,  975 
illustrative  cases,  979 
intra-uterine,  974 
pathological  anatomy,  973 
prognosis,  977 
symptoms,  974 
treatment,  978 
sinuses,  thrombosis  of  the,  998 
syphilis,  1004 
Cerebro-spinal  meningitis  {vide  Jleningitis, 
epidemic  cerebro-spinal) 
system,  tuberculosis  of  the,  400 
Cervicodynia,  1026 
Cheynes-Stokes  respiration,  404 
Chicken-broth,  preparation  of,  235 
Chicken-pox  {vide  Varicella) 
Chilblains,  359 

Chloral  hydrate,  doses  of,  931 
Chlorosis,  907 
Cholera  Asiatica,  495 
infantum,  823 

diagnosis,  824 
etiology,  823 

pathalogical  anatomy,  823 
prognosis,  824 
symptoms,  823 
treatment,  824 
Chondrodystrophia  foetalis,  331 

diagnosis  from  rhachitis,  326 
hyperplastica,  331 


1040 


INDEX. 


Chondrodystrophia  foetalis  hypoplastica, 
331 
malacica,  331 
Chorea,  932 

electrica,  941 
etiology,  933 
habit,  941 
hereditary,  940 
Huntington's,  940 
illustrative  cases,  937-940 
pathological  anatomy,  934 
post-hemiplegic,  976 
prognosis,  935 
Sydenham's,  932 
sjnnptoms,  934 
treatment,  936 
Chorea,  congenital,  1000 
Choroido-iritis,    in   cerebro-spinal   menin- 
gitis, 436 
Chrysarobin,  dose  of,  368 
Chvostek's  symptom,  965 
Chyluria,  854 
Circulation,  foetal,  19 

of  premature  infants,  252 
Cirrhosis  of  the  liver,  841 
atrophic,  842 
hypertrophic,  842 
Cleft-palate,  278 
Closets,  in  nursery,  89 
Clothing,  92  to  100 

abdominal  bands,  93 
dress,  94 
long  clothes,  94 
napkins,  93 
petticoat,  94 
shirt,  94 
short  clothes,  96 
stockings,  96 
Club-foot,  297 
Club-hand,  297 

Coagulation  {vide  Milk,  cow's) 
Colles's  law,  514 
Colon,  dilatation  of,  791 

normal  development  of,  64 
Colostrvim,  108,  115 
analyses  of,  116 
corpuscles,  116 
period,  116 
Coma,  diabetic,  1033 
Concussion,  960 

Congenital  (vide  also  New-born,  diseases 
of  the) 
dislocation  of  knee,  297 

of  hip,  297 
hydrocephalus,  277 
malformation  of  bile-ducts,  294 
of  oesophagus,  296 
of  stomach,  296 
obliteration  of  bile-ducts,  294 

of  intestines,  296 
stridor,  659 
umbilical  hernia,  288 
Conglomerate  tubercles,  379 
Constipation,  798 
atonic,  799 
spasmodic,  798 
treatment,  800 
Conus    arteriosus,    stenosis    of    the,    725 
Convulsions,  927 
central,  927 


Convulsions,  clonic,  927 
epileptic,  944 
general,  927 
general  symptoms,  928 
in  pertussis,  499 
of  central  origin,  928 
of  peripheral  origin,  929 
partial,  927 
peripheral,  927 
prognosis,  930 
reflex,  927,  929 
tonic,  927 
treatment,  930 
Cor  biloculare,  721 
triloculare,  721 
Cord,  at  term,  21 
care  of,  77 

normal  development  of,  39 
Corrigan  pulse,  745 
Corrosive     sublimate,     strength     of,     in 

injections,  875 
Coryza,  acute  638 
Cough,  reflex,  969 
Cow,  the,  162 

analysis  of  milk  of  different  breeds,  163 
Ayrshire,  162 
bacteria  in  milk,  166 
Bretonne,  162 
Brown  Swiss,  162 
care  of,  164 
care  of  milk  of,  166 
Devon,  162 
Durham,  162 
Guernsey,  163 
Holstein-Friesian,  162 
Jersey,  163 
Shorthorn,  162 
tuberculin  test  of,  166 
Cow-pox  (vide  Vaccinia) 
Cow's  milk  (vide  Milk,  cow's) 
Cranio  tabes  in  rhachitis,  320 

in  syphilis,  516,  521 
Cranium,  at  terai,  26 

proportions  of,  to  face,  44 
Creams,  176 

analysis  of,  168 
centrifugal,  179 

definition  and  composition  of,  183 
dilutions  of,  182 

fat  percentages  in  different  layers,  187 
method  of  obtaining,  186 
Crede's  method,  280 
Creolin,  strength  of,  in  injections,  875 
Cretinism  (ride  Myxoedema),  916 
endemic,  916 
sporadic,  916 
Crib,  infant's,  88 
Cricoid  cartilage,  normal  development  of, 42 

relation  to  sternum,  43 
Croup,  661 
Cry,  at  term,  21 
Cryoscopy,  850 
Curtains,  in  nursery,  89 
Curves,  cervical,  24 
dorsal,  24 
lumbar,  24 
Cyclic  vomiting,  778 
Cystitis,  acute,  873 

chronic,  873 
Cytoryctes  variolae,  592 


INDEX. 


1041 


D. 

Dactylitis,  syphilitic,  516 

tubercular,  421 
Deaf-mutism,  566 
Deglutition  pneumonia,  691 
De  Laval  cream  separator,  211 
Dental  reflexes,  965 
Dentition,  difficult,  632,  633 

normal  development  of,  49,  50,  51 
Dermatitis,  358 
calorica,  359 

exfoliativa  neonatorum,  356 
medicamentosa,  359 
traumatica,  358 
venenata,  358 
Development,  arrested  psychical,  952 
normal  (vide  Normal  development) 
of  premature  infants,  249 
Devon  cow,  162 
Dextro-cardia,  721 
Diabetes  insipidus,  1031 
mellitus,  1032 

Bremer's  blood  test  in,  1034 
complications,  1034 
diabetic  coma,  1033 
diagnosis,  1034 
etiology,  1032 
pancreatic  form,  1033 
pathological  anatomy,  1033 
prognosis,  1035 
symptoms,  1033 
treatment,  1035 
urine  in,  1033 
Diaphragm,  at  term,  31 

relations  of,  52 
Diarrhoea,  acute  infectious,  815 
diagnosis,  820 
etiology,  818 

pathological  anatomy,  815 
prognosis,  821 
prophylaxis,  821 
symptoms,  818 
treatment,  821 
chronic  infectious,  822 
nervous,  acute,  801 

chronic,  S02 
tubular  (vide  also  Intestines,  diseases 
of  the),  802 
Diazo-reaction  in  typhoid,  444 
Diet  in  lactation  (vide  also  Feeding),  130 
Difficult  dentition,  632,  633 
Digitalis,  doses  of,  464 
Diphtheria,  451 

albuminuria  in,  466 
antitoxin  in,  462  to  466 
atypical  infections,  456 
complications,  459 
contagium  of,  452 
diagnosis,  460 
disinfection  in,  463 
doses  of  stimulants  in,  464 
effiorescence  in,  460 
etiology,  452 
feeding  in,  469_ 
immunization  in,  462 
incubation  of,  4,54 
intubation  in,  467 
Klebs-Loeffler  bacillus  in,  462 
laryngeal,  458 


Diphtheria,  laryngeal  stenosis  in,  459 
local  treatment,  466 
malignant  forms,  456 
nasal  form,  457 
operative  treatment,  467 
paralysis  in,  459 
pathological  anatomy,  453 
peripheral  neuritis  in,  459 
prodromal  symptoms,  454 
prognosis,  461 
prophylaxis,  461 
pseudo-diphtheritic  bacillus,  462 
pseudo-membrane  in,  460,  462 
sequelse,  459 
serum-therapy  in,  464 
stimulants,  doses  of,  464  ^ 

symptoms,  454 
tracheotomy  in,  467 
treatment  of,  463 
feeding,  469 
intubation,  467 
local,  466 
of  sequelse,  469 
tracheotomy,  467 
variations  in  tj^pe,  456 
Diplegia,  975 
Diplococcus    intraceUularis    meningitidis 

424 
Discharges,  intestinal,  81,  795 
Disseminated  sclerosis,  1011 
Diuretin,  dose  of,  747 
Draughts,  in  the  nursery,  89 
Drawers,  in  nursery,  89 
Dress  for  infant,  94 
Drugs,  in  disturbed  lactation,  131 

in  the  treatment  of  children,  244 
Ductus  arteriosus,  in  fcetal  circulation,  20 
I    persistence  of  the,  725,  729 
1  ^ost-natal  changes  in,  54 
Ductus  venosus,  post-natal  changes  in,  54 
Duodenum,  at  term,  34 
Dura  mater,  normal  development  of,  46 
Durham  cow,  162 
Dysentery,  amoebic  (vide  also  Diarrhoea, 

acute  infectious),  494 
Dyspepsia,  acute,  782 

chronic,  783 
Dyspnoea  (vide  symptoms  of  the  especial 

disease) 
Dystrophies,  1014 

progressive  muscular  (vide  IMuscular 
dystrophies) 

E. 

Ears,  at  term,  29 

diphtheria  of  the,  459 

diseases     of     the     (vide    also   Otitis 
media),  642 

examination  of,  243 

in  cerebro-spinal  meningitis,  430 

in  diphtheria,  459 

in  late  s^'philis,  532 

in  measles,  578,  588 

in  scarlet  fever,  542,  566 

normal  development  of  the,  46 

protrusion  of  the,  279 

reflex  symptoms  of,  966 
Eclampsia  infantum   (vi^le    Comnilsions) , 
927 


66 


1042 


INDEX. 


Eczema,  363 

contagiousness  of,  367 
erythematosum,  363 
madidans,  363 
papillosum,  363 
pustulosum,  363 
regional,  364 
squamosum,  363 
symptoms,  364 
treatment,  364 
universal,  364 
vesiculosum,  363 
Edebohls's  operation,  863 
Emphysema,  706 

compensatory,  706 
interstitial,  706 
obstructive,  706 
Empyema,  713 
diagnosis,  714 
etiology,  713 

pathological  anatomy,  713 
prognosis,  714 
symptoms,  713 
treatment,  715 
Emulsion,  in  modified  milk,  205 
Encephalitis,  acute,  1008 
Encephalocele,  276 
Endocarditis,  735 
acute,  735 

acute  ulcerative,  736 
etiology,  735 
leucocytosis  in,  739 
malignant,  738 
septic  type,  739 
simple,  735 
treatment,  739 
typhoidal  type,  739 
ulcerative,  738 
verrucose,  735 
chronic,  740 

acute  dilatation  in,  746 
aortic  insufficiency  in,  743 

stenosis  in,  744 
diagnosis,  745 
dropsy  in,  747 
^  dyspnoea  in,  747 

etiology,  740 
general  symptoms,  740 
mitral  insufficiency,  741 

stenosis,  741 
nervous  symptoms  in,  748 
pathological  anatomy,  740 
prognosis,  745 
pulmonary  insufficiency,  745 

stenosis,  745 
treatment,  746 
tricuspid  insufficiency,  744 

stenosis,  745 
valvular  insufficiency,  740 

stenosis,  740 
vomiting  in,  747 
fcetal,  720 
Enemata,  nutrient,  781 
Enteric  fever  ("ide  Typhoid  fever),  439 
Enuresis,  877 
etiology,  877 
functional,  877 
organic,  877 
prognosis,  878 
symptoms,  878 


Enuresis,  treatment,  878 
Epididymitis,  876 

Epiglottis,  normal  development  of,  42 
Epilepsy,  942 

aura  in,  944 

diagnosis,  945 

epileptic  status  in,  944 

etiology,  943 

grand  mal,  944 

Jacksonian,  942 

massed,  944 

petit  mal,  943 

prognosis,  945 

psychic,  945 

symptoms,  943 

Tourette's  mixture  in,  946 

treatment,  946 
Epiphyseal  hypersemia,  1031 
Epiphysitis,  acute,  502 
Epispadias,  294 
Epistaxis,  642 

Erb's  juvenile  form  of  muscular[[atrophy, 
1019 

type  of  paralysis,  992 
Erysipelas,  490 

ambulans,  490 

chronic,  494 

incubation  in,  491 

migrans,  490 

of  sucklings,  491 

of  the  new-born,  491 

pathological  anatomy,  490 

symptoms,  490 

treatment,  492 
Erythema,  360 

intertrigo,  361 

multiforme,  360 

neonatorum,  310 

nodosum,  362 

simplex,  360 

urticatum,  362 
Erythrocytes,  882,  887 
Eustachian  tubes,  at  term,  28 

normal  development  of,  47 

valve,  in  foetal  circulation,  20 
post-natal  changes  in,  54 
Ewart's  sign,  758 

Examination,  general  principles  of   236 
Exanthemata,  535 

differential  diagnosis  of  the,  609 
Exercise,  for  infants,  100 

in  lactation,  131 
Exophthalmic  goitre,  921 
Extremities,  diseases  of,  in  the  new-born, 
296 

in  rhachitis,  323 
Eyes,  at  term,  21,  29 

in  cerebro-spinal  meningitis,  430 

in  early  syphilis,  518 

in  late  syphilis,  531 

in  measles,  589 


Face,  at  term,  26 

proportions  of,  to  cranium,  44 
Faecal  dejections,  influence  of  fats  on,  229 
Faeces,  796 _ 

incontinence  of,  798 
Family  periodic  paralysis,  1013 


INDEX. 


1043 


Fat-free  milk,  176 

analysis  of,  168 
definition  of,  183 
method  of  obtaining,  186 
Fats   {vide  also  Milk),  estimation  of,   by 
Babcock  method,  212 
influence   of,   on   dejections,  229 
management    of,    in    feeding,    198 
volatile,     in    Jersey    and    Guernsey 
milks,  163 
Faucial  tonsils,  at  term,  29 
Feeding,  106 

after  thirtieth  month,  235 
by  gavage,  785 
general  principles,  106 
in  second  year,  232 
mixed,  150 
Feeding  card,  189 
Feeding,  direct  stibstitute,  154 
animals  in,  158 
wet-nurses,  156 
Feeding,  indirect  substitute,  158 

administration  of  milk  in, 193 

alkalies  in,  190 

apparatus  for  modification, 

184  _ 
artificial  foods  for  infants,229 
butter-milk  in,  231 
calculation  by  formulse   in, 

193 
calculation     of     percentage 

combinations  in,  187 
calculation    of    percentages 
from  known  mixtures  in, 
195 
caloric    value    of    modifica- 
tions in,  201 
care  of  miUc  in,  166 
cereals,  use  of,  in,  191,  204 
cow,  the,  in,  162 
difficult     cases     of    feeding 

in,  199 
emulsion   of   modified   milk 

in,  205 
force_d  {vide  Gavage) 
general   considerations,    158 
illustrative  cases  in,  221-228 
kimayss  in,  231 
Ladd's  feeding  card  in,  189 
management  of  fats  in,  198 
management  of  proteids  in, 

198,  220 
management  of  sugars  in,  198 
materials    for    modification 

of  milk  in,  183 
matzoon  in,  231 
method  of  obtaining  cream 

in,  186 
method  of  obtaining  fat-free 

milk  in,  186 
milk-laboratories     in     {vide 
Milk-laboratories),  208  to 
221 
mixing  milk  in,  193 
peptonization  of  milk  in,  203 
rules  for  feeding  in,  1S6 
source  of  food,  160 
sources  of  error  in  modifica- 
tion in,  201 
sterilization  of  milk  in,  217 


Feeding,    indirect    substitute,    theory    of 
percentage  modification  of 
milk  in,  180 
whey-mixtures  in,  191,  220 
Feeding,  maternal,  110 

breast-milk  (ride  Milkjhuman), 114 
breast-pump,  113 
contra-indications  to,  110 
diet,  130 

disturbed  lactation,  131 
exercise,  131 

illustrative  cases  of,  137  to  149 
interv^als  of,  128 

management  of  disturbed  lacta- 
tion, 133 
management  of,  in  early  davs  of 

life,  127 
mastitis,  112 

menstruation,  influence  of,  in,  132 
nipples.  111 
normal  conditions,  110 

lactation,  129 
nursing.  111 

pregnancy,  influence  of,  in,  133 
prolonged  lactation,  150 
regimen  of  lactation,  130 
rules  for  the  management  of  dis- 
turbed lactation,  136 
weaning,  151 
Feeding  of  premature  infants,  260 
amount,  261 
caloric  need  of,  261 
inter\'als,  262 
percentages,  262 
Feet,  at  term,  37 
care  of,  96 

in  premature  infants,  257 
normal  development  of,  76 
shoes  for,  98 
Femoral  hernia,  291 

Fermentation,   influence  of  heat  on,^  170 
in  milk,  170 
of  milk-sugar,  170 
Fibroid  phthisis,  695 
Filaria  sanguinis  hominis,  854 
Fingers,  in  the  new-born,  296 
Fissures,  794 
Fistulge,  831 
Flail  joints,  983 
Flat-foot,  76,  324 
Floor  in  nurserj^,  88 
Foetal  circulation,  19 

ductus  arteriosus  in,  20 
Eustachian  valve  in,  20 
foramen  ovale  in,  20 
umbilical  arteries  in,  20 
veins  in,  20 
rhachitis,  333 
Foetus,  t^-phoid  in  the,  439 
Fontaneiles,  at  tenn,  25 

normal  deA'elopment  of  the,  44 
Foramen   ovale,    in   foetal   circulation,  20 
open,  723 

post-natal  changes  in  the,  54 
Foreign  bodies  in  larjTix,  660 
Fore-milk,  125 

Formute   for   calculating   milk   modifica- 
tions {vide  Feeding) 
Fossa  of  RosenmiUler.  28 
Foster-feeding  (j'?We  Wet-nurses\  156 


1044 


INDEX. 


Fowler's  solution,  dose  of,  904,  936 
Freckles,  372 
Friedreich's  disease,  1012 
Frozen  section  of  a  child,  53 
Functions,  in  infant  at  term,  37 
normal  development  of;  77 
Fungus  of  umbilicus,  288 
Funnel  chest,  321 
Furniture  in  nurseiy,  89 
Furunculosis,  352 

G. 

Gasping,  paroxysmal,  968 
Gastritis,  catarrhal,  787 

chronic,  789 

corrosive,  787 

infectious,  787 

pseudo-membranous,  788 

ulcerative,  787 
Gastro-enteric    tract,    classification    of 

diseases,  770 
Gavage,  785 
Gelatin,  dose  of,  308 
Genitals,  diseases  of  the,  873 
Genus  anopheles,  474 

culex,  475 
German  measles  {vide  Rubella) 
Glossitis,  631 

Glycosuria  {vide  also  Diabetes  mellitus), 
1032 

alimentary,  855 

dietetic,  855 
Goat's  milk,  161 
Goitre,  914 

exophthalmic,  921 
Gout,  chronic,  1028 
Graefe's  symptom,  921 
Grand  mal,  944 
Green  sickness,  908 
Growing  pains,  1031 
Guernsey  cow,  163 

volatile  fats  in  milk  of,  163 
Gum-lancing,  634 
Gums,  at  term,  27 
^Gyrospasm,  966 

H. 

Habit  spasms,  941 

Hsematoblasts,  882 

Hsematoma  of  the  stemo-cleido-mastoid, 

281 
Hsematuria,  853 
Haemoglobin,  881,  887 
Heemoglobinuria,  853 

infectious,  300 

paroxysmal,  854 
Hsemopericardium,  754 
Hsemophilia   {vide    also    Hemorrhage    in 

early  life),  1021 
Hair,  at  term,  21 
Hands,  at  term,  37 
Hard  palate,  at  term,  29 

normal  development  of  the,  47 
Harelip,  277 

Harrison's  groove  in  rhachitis,  321 
Head,  at  term,  25 

diseases  of  the  new-born,  272 

in  premature  infants,  249 


Head,  in  rhachitis,  320 

relative  proportions  to  thorax,  43 
Headache,  961 
Hearing,  at  term,  38 

Heart,    acquired    diseases    of    the     {vide 
Endocarditis,  acute),  730 
at  term,  21,  32 

chronic   disease   of   the    {vide   Endo- 
carditis, chronic) 
congenital  diseases  of  the,  720 

cardiac  hypertrophy  in,  727 
defect    of    the    ventricular 

septum,  724 
differential  diagnosis  of,  726 
general  diagnosis,  723 
general  symptoms,  721 
general  treatment,  730 
lesions  of  aortic  valves,  726 

of  mitral  valve,  726 
murmurs  in,  727 
open  foramen  ovale,  723 
persistence    of    the    ductus 

arteriosus,  725,  729 
pulmonary  atresia,  725 

stenosis,  724,  728 
stenosis  of  the  conus  arteri- 
osus, 725 
thrill  in,  727 
transposition    of    the    large 

arteries,  726 
tricuspid  insufficiency,  726 
stenosis,  726 
dilatation  of  the,  732 
acute,  732 
chronic,  732 

differential  diagnosis  from  peri- 
cardial effusion,  761 
diseases  of  the,  719 

illustrative  cases  of,  749  to  753 
functional  diseases  of  the,  748 
diagnosis,  748 
etiology,  748 

hsemic  murmurs  in,  748,  749 
prognosis,  749 
symptoms,  748 
treatment,  749 
hypertrophy  of  the,  731 
in  rhachitis,  325 
in  scarlet  fever,  548 
normal  development  of  the,  54 
■    post-natal  changes  in  the,  54 
reflex  symptoms  of,  970 
relations  according  to  age,  82,  86 
weight  of,  during  development,  55 
Heat,  action  of,  on  milk,  172,  175 
Heating,  in  nursery,  89 
Heat-stroke,  958 
Heberden's  nodes,  1029 
Height,  at  term,  36 

from  birth  to  fourteen  years,  76 
normal  development  of,  68 
Hemiataxia,  976 
Hemichorea,  935 
Hemiplegia,  975 
Hemorrhage  in  early  life,  303 

in  infantile  scorbutus,  337,  339 
in  syphilis,  519 
of  umbilicus,  39,  306 
Hemorrhagic  diathesis,  1021 

disease  of  the  new-born,  303 


INDEX. 


10-40 


Hemorrhoids,  795 
Hepatitis,  interstitial,  841 

suppurative,  839 
Hereditary'  ataxia,  1012 
spastic  paralysis,  1013 
sj^liilis,  diagnosis,  327 
Hernia,  794 

femoral,  291 
incarcerated,  289 
inguinal,  290 

congenital,  290 
encysted,  290 
funicular,  290 
infantile,  290 
treatment,  291 
strangulated,  289 
umbilical,  288 
Heroin,  dose  of,  501 
Herpes  zoster,  369 
Hip,  tuberculosis  of  the,  420 
History',  method  of  taking,  237 
Hives,  362 

Hodgkin's  disease,  898 
Holstein-Friesian  cow,  162 
Home  modification  of  milk,  180 
Hmnan  milk  {vide  Milk,  human),  114 
Huntington's  chorea,  940 
Hutchinson's  teeth,  530 
Hydatids,  of  liver,  840 
Hydrocele,  291 

congem'tal.  291 

encysted,  of  canal  of  Xuck,  292 

of  cord,  292 
funicular,  291 
infantile,  291 
treatment,  292 
Hydrocephalic  cr\^  402 
Hydrocephalus,  993 

acute,  etiologj^,  993 
sjTiiptoms,  993 
chronic  internal,  acquired,  994 
congenital,  994 
diagnosis,  995 
pathological  anatomy,  994 
prognosis,  996 
sjTnptoms,  994 
treatment,  996 
congenital,  277 
diagnosis  from  rhachitis,  328 
external,  993 
illustrative  cases,  997 
in  vacuo,  993 
Hydro-encephalocele,  276 
Hydroneplirosis,  871 
Hydropneumothorax,  717 
Hydrotherapy,  techniciue  of,  in  t\'phoid,447 
Hvdrothorax,  717 

Hj-perpvrexia,  treatment  of,  by  bathing,447 
BvpeTthyrea.,  921 
HjTJertrophy,  cardiac,  731 
HjTDOspadias,  294 
Hysteria,  954 


Ichthyosis,  373 

fffital,  373 

neonatorum,  374 
Icterus,  838 

neonatorum,  309 


257 


Idiocy,  947 

diagnosis,  950 
etiology,  948 
Mongolian,  950 
pathological  anatomy,  948 
sjinptoms,  949 
treatment,  952 
Ileo-colitis,  acute    {inde   Diarrhoea,  infec- 
tio'os),  815 
amoebic,  494 
tubercular,  394 
tj'phoidal,  439 
Imbecility,  947 

Immunization  in  diphtheria,  462 
Impetigo  contagiosa,  351 
Incontinence  of  feeces,  798 

of  urine,  877 
Incubators,    for   premature    infants. 
Indigestion,  duodenal,  acute,  803 
chronic,  803 
intestinal,  acute,  802,  807 

from  deficient  secretion,  807 
from  fermentation,  808 
prophylaxis  in,  810 
treatment  of,  811 
chronic,  812 

treatment,  813 
gastric,  acute,  782 
chronic,  783 
Infant,  at  tenn,  21 

abdomen  in,  33 

bile  in,  38 

bladder  in,  36 

blood  in,  38 

bone-marrow  in,  37 

brain  in,  29 

Brunner's  glands  in,  35 

bursa  pharsmgea  in,  28 

carotid  arten,-  in,  32 

craniimi  in,  26 

diaphragm  in,  31 

duodenum  in,  34 

ear  in,  29 

Eustachian  tubes  in,  28 

eye  in,  29 

face  in,  26 

faucial  tonsils  in,  28 

feeding  of  average,  228 

feet  in,  37 

fcetal  circulation  in,  19 

fontanelles  in,  25 

functions  of,  37 

general  descriptions  of,  21 

gvmos  in,  27 

hands  in,  37 

hard  palate  in,  29 

head  in,  25 

hearing  in,  38 

heart  in,  32 

height  in,  36 

intestinal  discharges  in,  39 

intestines  in,  35 

jaws  in,  26 

lachrj-mal  glands  in,  38 

large  intestines  in,  36 

larj-nx  in,  25 

liver  in,  33 

lungs  in,  32 

Ijonphatic  systein  in,  39 

Ijinphoid  tissue  in,  28 


1046 


INDEX. 


Infant,  at  term,  mastoid  antnun,  29 

meconium  in,  39 

mouth  in,  29 

naso-pharynx  in,  27 

neck  in,  24 

ossification  of  sternum  in,  30 

pancreas  in,  38 

pelvis  in,  36 

petro-squamosal  suture  in,  30 

pharyngeal  Ijinph-vessels  in,  27 
tonsil  in,  28 

pulmonary  artery  in,  32 

pulse  in,  36 

respiration  in,  30,  36 

salivary  glands  in,  38 

sebaceous  glands  in,  38 

sight  in,  37 

sigmoid  flexure  in,  36 

skin  in,  21 

small  intestines  in,  36 

smell  in,  38 

soft  palate  in,  29 

spine  in,  22 

sternum  in,  30 

stomach  in,  34 

supra-renal  capsules  in,  34 

sweat  glands  in,  38 

taste  in,  38 

teeth  in,  29 

temperature  in,  36,  65 

thorax  in,  30 

thymus  glands  in,  32 

tongue  in,  29 

touch  in,  38 

uric  acid  infarction  in,  34 

urine  in,  39 

uterus  in,  36 

uvula  in.  29 

veins  in,  32 

vernix  caseosa  in,  21 

vitality  in,  37 

voice  in,  37. 

weight  in,  36 
Infantile  cerebral  paralysis,  972 
spinal  paralysis,  981 
fant,  normal,  17 
Infectious  diseases,  specific,  376 
hsemoglobinuria,  300 

diagnosis,  303 

etiology,  301 

pathological  anatomy,  302 

symptoms,  302 

treatment,  303 
Influenza,  469 

diagnosis,  471 
etiology,  469 
febrile  form,  471 
gastro-enteric  form,  471 
incubation,  469 
nervous  form,  471 
prognosis,  472 
pseudo  form,  469 
respiratory  type,  470 
symptoms,  470 
treatment,  472 
variations  in  type,  470 
febrile,  471 
gastro-enteric,  471 
nervous,  471 
respiratory,  470 


Inguinal  hernia,  290 
Inheritance,  in  the  new-born,  268 
Insolation,  958 

Inspection,  in  physical  examination,  238 
Insular  sclerosis,  1011 
Intermittent  fever  {vide  Malaria) 
Intertrigo,  361 
Intervals  of  feeding,  128 
Intestinal  contents  in  premature  infants, 
251 
discharges,  39,  81,  795  ; 

indigestion    (vide    Indigestion,  intes- 
tinal, acute  and  chronic) 
worms  {vide  Worms),  831 
Intestines,  at  term,  35 

diseases  of  the,  770,  790 

cholera  infantum,  823 

congenital  obliteration,  296 

constipation,  798 

developmental.  790 

dilatation,  791 

functional,  797 

hemorrhage  from  the,  305 

indigestion,  802 

infectious,  815 

intussusception,  792 

mechanical,  790 

new  growths,  795 

non-infectious,    790 

tubular,  802 

volvulus,  792 
normal  development  of,  63,  64 
Intra-cranial  tumors,  1001 
Intubation,  in  diphtheria,  467 
Intussusception,  792 
Iodide  of  potassium,  doses  of,  532 
Iritis,  in  measles,  589 
Iron,  doses  of,  908 

lactate,  908 

ovoferrin,  908 

sacchrated   carbonate,  908 

tartrate  of,  and  potassium,r908 
Irrigation  of  the  colon,  821 
of  the  eyes,  281 
of  the  stomach,  784 
Ivy  poisoning,  358 

J. 

Jacksonian  epilepsy,  942 
Jaundice  in  the  new-born,  309 
Jaws,  at  term,  26 
Jersey  cows,  163 

volatile  fats  in  milk  of,  163 
Joints,  atrophic  diseases  of  the,  1027 

hypertrophic    diseases    of    the,    1027 
in  cerebro-spinal  meningitis,  431 
in  scarlet  fever,  571 
tuberculosis  of  the,  418 

pathological  anatomy,  419 
symptoms,  420 
treatment,  421 
Juvenile  tabes,  1012 

K. 

Kakke,  1009 
Kaposi's  disease,  372 
Keratitis,  in  measles,  589 

interstitial  syphilitic,  532 


INDEX. 


1047 


Kernig's  sign,  404 

Kidneys,  acquired  diseases  of  the,  848 
(vide  also  Nephritis) 

acute  degeneration,  856 
nephritis,  858 

amyloid  infiltration,  865 

at  term,  33 

chronic  nephritis,  863 

classification  of,  856 

congenital,  848 

enlargement,  872 

general  etiology,  848 
pathology,  848 
symptomatology,  850 

in  cerebro-spinal  meningitis,  427 

in  diphtheria,  459 

in  malaria,  478 

in  premature  infants,  252 

in  scarlet  fever,  568 

in  syphilis,  516 

malignant  growths,  872 

normal  development  of,  57 

passive  congestion,  857 

relations  according  to  age,  82-86 

tuberculosis  of,  422 
Knee,  tuberculosis  of  the,  421 
Koplik  spots,  580,  591 
Kumyss,  231 
Kj^hosis,  323 


Laboratories  (vide  Milk  laboratories),  208 
Lachrymal  glands  at  term,  38 

normal  development  of,  77 
Lactalbumin  (vide  Whey-proteids),  191 
Lactation,  diet  in,  130 

disturbed,  131 

acute  illness  in,  133 
drugs,  131 

management  of,  133,  136 
menstruation,  132 
pregnancy,  133 

exercise  in,  131 

prolonged,  150 

regimen  of,  130 
Lactose  (vide  Milk-sugar),  169 
Lagophthalmia,  991 
La  grippe  (vide  Influenza),  469 
Landouzy-Dejerine     type     of     muscular 

atrophy,  1019  _ 
Landrj^'s  paralysis,  1010 
Lanugo,  in  premature  infants,  248 
Large  intestines,  at  tei-m,  36 

mononuclear  cells,  883 
LarjTigismus  stridulus,  659 
Laryngitis,  661 

acute  catarrhal,  661 

chronic  663 

pseudo-membranous,  663 
Laryngospasmus,  659 

in  rhachitis,  324 
Larjmx,  at  term,  25 

diphtheria  of,  458 

diseases  of  the,  659 

foreign  bodies  in  the,  660 

new  growths,  659 

nonnal  development  of,  42 

oedema  of  the,  661 

reflex  symptoms  of.  966 


Lavage  of  stomach,  784 

contra-indications,  785 
Leg  type  of  progressive  muscular  atrophy, 

1016 
Legs,  development  of,  105 
Lentigo,  372 
Leptomeningitis,  1005 
Leucocytes,  882,  887 
origin  of  the,  885 

percentage  of,  in  normal  blood,  884 
Leucocytosis,  diseases  in  which  it  is 
absent,  888 
diseases  in  which  it  is  present,  888 
in  diseased  conditions    (vide  the  dis- 
ease in  question) 
physiological,  886 
Leukaemia,  889 
diagnosis,  891 
illustrative  cases,  892-898 
lymphatic,  889 
mixed  forms,  890 
pathological  anatomy,  889 
prognosis,  891 
splenic  myelogenous,  889 
symptoms,  890 
treatment,  892 
Lichen,  372 

planus,  372 
Lime-water  (vide  Alkalies),  190 
Lingua   geographica,  631 
Little's  disease,  975 
Liver,  at  term,  21,  23 
diseases  of  the,  837 
abscess,  839 

acute  yellow  atrophy,  838 
amyloid,  840 
biliary  calculi,  840 
cirrhosis,  841 
congestion  of,  838 
fatty  infiltration,  839 
hydatids,  840 
icterus,  838 
in  cerebro-spinal   meningitis,  426 
in  malaria,  478 
in  rhachitis,  325 
in  syphilis,  516 
in  tuberculosis,  422 
malformations,  837 
malpositions,  837 
new  growths,  840 
normal  development  of,  56 
relations  according  to  age,  82-86 
size  of,  837 
Lobular  pneumonia  (vide  Pneumonia, 

acute  broncho-) 
Locomotor  ataxia,  1012 
Lordosis,  323 
Lumbago,  1026 

Lumbar   puncture,    diagnostic    value    of, 
•     243,  406,  431 
Lung,  abscess  of  the,  707   - 
at  term,  21,  32 
diseases  of  the,  664 
gangrene  of  the,  707 
in  cerebro-spinal  meningitis,  426 
in  diphtheria,  459 
in  rhachitis,  324 
in  SA-philis,  516 
normal  development  of,  55 
reflex  sjanptoms  of,  968 


1048 


INDEX. 


Lung,  relations  according  to  age,  82  to  86 
Lupus,  423 

Lymphangioma  cavernosum,  632 
Lymphatic  system,  at  term,  39 

normal  development  of,  79 
Lymphatism,  1024 
Lymph-nodes,  diseases  of  the,  912 

in  cerebro-spinal  meningitis,  426 

in  measles,  589 

in  rhachitis,  325 

in  scarlet  fever,  544,  565 

in  sjTDhilis,  518 

tuberculosis  of  the,  384 
Lymphocytes,  883 
Lymphoid  tissue,  at  term,  28 
Lymph- vessels,  pharyngeal,  at  term,  27 

M. 

Macrocytes,  887 
Macroglossia,  632 
Malaria,  474 

sestivo-autumnal  type,  477 

chronic,  481 

combination  of  paroxysms  in,  479 

diagnosis,  481 

etiology,  474 

illustrative  cases,  483-488 

intermittent  type,  478 

mosquitoes  as  a  cause  of,  474 

pathological  anatomy,  478 

Plasmodium,  476 

prognosis,  481 

prophylaxis,  482 

quartan  types,  477 

remittent  type,  478 

subacute,  481 

symptoms,  478 

table   showing   combination   of   par- 
oxysms, 479 

tertian  type,  477 

treatment  482 

white  blood  count  in,  481 
Male-fern,  dose  of,  835 
Malformations  about  the  rectum,  293 

in  the  new-born,  268' 
~~"      of  bile-ducts,  294 

of  extremities,  296 

of  heart,  296 

of  intestines,  296 

of  oesophagus,  296 

of  stomach,  296,  770 
Malignant    growths    (vide    New    growths 

and  tumors) 
Malpositions,  of  stomach,  770 
Malted  foods   {vide  Proprietary  foods) 
Mammary  gland,  functions  of,  107-109,  111 
Mammitis,  infectious,  166 
Marasmus,  341 
Mare's-milk,  161 
Mast-cells,  884 
Mastitis,  112,  282 
Mastoid  antrum,  at  birth,  29 
Mastoiditis,  in  measles,  579 

in  scarlet  fever,  543 
Masturbation,  879 
Maternal  feeding  {vide  Feeding,  maternal) 

impressions,  271 
Mattress,  infant's,  88 
Matzoon,  231 


Maxillary  bones,  normal  development  of, 

48 
Measles,  575 

blood  in,  579 

broncho-pneumonia  in,  587 
complications,  587 
contagium,  576 
desquamation,  581 
diagnosis,  581 
ears  in,  578 
efflorescence,  581 
enlarged  lymph-nodes  in,  589 
etiology,  575 
eye  complications  in,  589 
hemorrhagic  form,  585 
incubation,  579 
Koplik  spots,  580 
Isevis  form,  585 
malignant  form,  585 
mastoiditis  in,  579 
miliarius  form,  585 
nephritis  in,  589 
noma  in,  590 
otitis  media  in,  588 
paralysis  in,  590 
pathological  anatomy,  577 
pertussis  in,  587 
pleuritis  in,  588 
prodromal  efflorescence,  580 
prodromata,  579 
prognosis,  582 
recurrent  form,  586 
relapses,  586 
se(^uelae,  587 

susceptibility  to  tuberculosis  in,  579 
symptoms,  579 
thyroid  hypersemia  in,  589 
treatment,  582 
tuberculosis  in,  589 
variation  in  type.  584 
Measure,  sugar,  185 
Meckel's  diverticulum,  288 
Meconium,  39 
Megalo blasts,  903 
Megalocytes,  903 
Melaena  neonatorum,  306 
Melanin,  476 

Melanoderma  lenticularis  progressiva,  372 
Membranous  croup,  661 
Meningitis,  1005 
basilar,  1006 

epidemic   cerebro-spinal,   423 
chronic,  427 
diagnosis,  431 
etiology,  424 
fulminating  forms,   427 
illustrative  cases,  433-439 
intermittent,  427 
mild  forms,  427 
pathological  anatmoy,  424 
prognosis,  432 
symptoms,  427 
treatment,  432 
types  of  the  disease,  427 
serosa,  993 
simple  acute,  1005 
tubercular,  401 

differential  diagnosis  of,  406 

from  acute  meningitis, 
409 


INDEX. 


1049 


Meningitis,  tubercular,  differential  diag- 
nosis from  anterior 
poliomyelitis,  407  } 

from  cerebro-spinal  men- 
ingitis, 409  I 
from  diseases  of  stom- 
ach, 406 
from  malaria,  407 
from  nephritis,   407 
from  pneumonia,  407 
from  syphilis,   408 
from  typhoid  fever,  408 
etiology,  401 

illustrative  cases,  410-418 
infantile  form,  405 
pathological  anatomy,  401 
prognosis,  410 
symptoms,  402 
treatment,  410 
Meningocele,  275 

spinal,  284 
Meningo-myelitis,  981 
Meningo-myelocele,  284 
Menstruation,  in  disturned  lactation,  132, 
Mental  impressions,  77 
Mercurials,  doses  of,  524 
Microcephalvis,  754 
Micrococcus  lanceolatus,  675 
Microcytes,  887 
Microglossia,  632 
Microsporon  furfur,  354 
Middle  milk,  125 
Migraine,  961 
Miliary  tubercles,  379,  385 

tuberculosis,  382 
Milk,  ass's,  161 
Milk,  colostrum,  115 
Milk,  cow's,  albumin  in,  173 
analysis  of,  168 

of  creams  froin,  168 
of  fat-free  milk  from,  168 
of  whey  from,  168 
attenuants  of,  177 
bacteria  in,  178,  179 
calcium-casein  in,  173 
care  of,  164,  166 
caseinogen  in,  171 
chemistry  of.  167-176 
choice  of ,  in  substitute  feeding,  1 60 
compared  with  human  milk,  177 
compared  with  other  animals',  161 
creams  from,  177 
dilutions  of,  182 
effect  of  cold  on,  176 
emulsion  of,  177 
fat-free,  176 
fats  in,  169 
formation  of,  114 
gases  in,  175 

heat,  action  of,  on,  172,  175 
lactose  in,  169 
milk-plasma  in,  169 
milk-sugar  in,  169 
mineral  matter  in,  174 
nitrogenous  extractives  in,  173 
pasteurization  of,  175 
percentage  modification  of,  180 
preservatives  in,  167 
production  of  sterile,  178 
reaction  of,  169 


Milk,  cow's,  rennet-coagulation  of,  171, 172 
salts  of   {vide  Mineral  matter) 
specific  gravity  of,  169 
sterilization  of,  175 
temperature  for  giving  milk,  214 
water  in,  174 
whey-proteids  in,  173 
Milk-fat,  origin  of,  114 
Milk,  human,  114 

analyses  of  normal  and  abnormal, 

137-149 
average  composition  of,  120 
bacteriological    examination    of, 

127 
clinical  examination  of,  117 
comparison   with   that   of   other 

animals,  161 
composition,  114 

of  abnormal  specimens,  134 
fat  estimation,  118,  121 
formation  of,  114 
Harrington's  analysis  of,.  126 
microscopic  examination  of,  120 
mineral  matter,  123 
nervous    disturbances    affecting 

the,  115 
proteids  in,  118,  122 
reaction  of,  121 
salts,  119 

specific  gravity  of,  118,  121 
sugar  in,  119,  122 
variations  in  composition  of,  125 
water  in,  121 
whey-proteids  in,  173 
Milk-laboratories,  208 

apparatus  for  transportation  of 

milk,  213 
care  of  milk  in,  210 
centrifugal  cream  mixtures,  215 
De  Laval  separator,  211 
gravity-cream  mixtiires,  215 
limitations  of  starch  percentages 

in,  216  ■ _ '  ? 

limits  of  cream  modifications,  219 
materials  for  modification,  214 
milk-room,  210 

modified  milk  by  the  quart,  216 
modifying-room,  191 
pasteurization  of  milk  in,  217 
prescription  ^mting  in,  218 
separating-room,  211 
sterilization  of  milk  in,  217 
still,  191 
ventilator,  211 
whev-mixtm-es  in,  220 
Milk,  mare's,''l61 
Milk  of  magnesia,  doses  of,  800 
Milk-proteids.  origin  of,  114 
Milk,  separated,  176 
Milk-sugar,  169 

fermentation  of,  170 
management  of,  in  feeding.  198 
origin  of,  115 

rule  for  calculating  percentages 
of,  190 
Mirror  writing,  954 

Mitral  orifices,  congenital  disease  of,  726 
valve,  disease  of  the,  741 
insufficiency,  741 
stenosis,  741 


1050 


INDEX. 


Mixed  feeding,  150 

Modification    of    milk    {vide    Percentage 

modification),  180 
Modified  milk,  by  the  quart,  216 
definition  of,  180 
emulsion  in,  205 
MoUuscum  contagiosum,  352 
Mongolian  idiocy,  950 
Monoplegia,  975 

Morbus  inac\ilos\is  Werlliofii,  1024 
Morphia,  doses  of,  812 
Mosquitoes,  in  malaria.  474 
Mouth,  at  term,  29 
care  of,  101 

disease  of  the  (viile  Stomatitis),  613 
nomenclature,  613 
inspection  of,  242 
in  sj^philis,  520 
normal  development  of,  48 
■n-ash,  652 
Movements,  intestinal,  795 
Multiple  neuritis,  1009 
Mumps,  611 

submaxillarj',  612 
Murmurs,  cardiac,  functional,  749 

organic,  749 
Muscular  atrophy,  1014 

progressive  central,  1014 
diagnosis,  1015 
etiology,  1014 
pathological     anatomy, 

1014  _ 
prognosis,  1015 
sjmiptoms,  1015 
treatment,  1015 
progressive  neural,  1016 
diagnosis,  1016 
etiology,  1016 
pathological     anatomy, 

1016 
prognosis,  1017 
sTfTnptoms,  1016 
treatment,  1017 
Muscular  dystrophies,  progressive,  1017 

atropliic  forms,  1019 
-^  classification,  1017 

diagnosis,  1019 
Erb's  juvenile  form,  1019 
etiology,  1018 

Landouzy-Dejerine  type,  1019 
pathological  anatomy,  1018 
prognosis,  1019 

pseudo-h-s-pertrophic  forms,  1018 
treatment,  1020 
Mutton-broth,  235 
Myalgia,  1025 
Mvcelium,  624,  626,  627 
Mvelitis,  981 
Myelocj^es,  884 
Myocarditis,  733 

amyloid  degeneration  in,   734 

angemic  necrosis,  733 

brown  atrophy,  734 

calcareous  degeneration,  734 

diagnosis,  734 

etiologj",  733 

fatty  degeneration,  734 

fatty  infiltration,  734 

hyaline  transformation  in,   734 

interstitial  form,  733 


Myocarditis,  parenchjonatous  form,  733 

pathological  anatomy,  733 

prognosis,  734 

symptoms,  734 

treatment,  735 
Myoclonia,  942 
Myopathies,  1014 

primary    {vide  Muscular  dj'strophies), 
1017 
Myotonia,  congenita,  941 
Myotonic  reaction,  941 
Myxoedema,  916 

acquired,  916 

congenital,  916 

diagnosis,  917 

operative,  916 

pathological  anatomy,  916 

symptoms,  916 

treatment,  918 
Myxoma  of  brain,   1001 

N. 

Naevus,  312 

Nails,  in  sj'philis  {vide  also  Onychia),  518 
Napkins,  93 
Nasal   diphtheria,    457 
Naso-pharjTix,   at  term,   27 
diseases  of  the,  644 
normal  development  of,  47 
Natiform  skull,  529 
Neck,  at  term,  24 

diseases  of,  in  the  new-born,  281 
normal  development  of,  42 
Nephritis,  858 

acute  glomerular,  858 

acute  stage,  859 
complications,  859 
convalescent  stage,  859 
differential  diagnosis,  860 
etiology,  858 
exacerbations,  859 
fatty  stage,  859 
pathological  anatomy,  858 
sjTnptoms,  858 
treatment,  860 
urine,  859 
acute  interstitial,  861 
chronic  glomerular,  863 
chronic  interstitial,  863 
chronic   parenchymatous,    861 
in  measles,  589 

in  scarlet  fever,  544  to  548,  568 
subacute  glomerular,  861 

diagnosis,  862 
pathological  anatomy,  861 
prognosis,  862 
sjTTiptoms,  861 
treatment,  863 
urine,  862 
Nervoxis  system,  diseases  of  the,  926 

in  cerebro-spinal  meningitis,  426 
in  late  sj^Dhilis,  532 
in  rhachitis,  324 
Nettle-rash,  362 
Neuralgia,  993 
Neuritis,  diphtheritic,  459 
multiple,  1009 

progressive    interstitial   hypertrophic 
of  infants,  1017 


INDEX. 


1051 


Neutrophiles,  884 

New-bom,  diseases  of  the,  268 

acute  fatty  degeneration,   298 
diagnosis,  300 
etiology,  298 
pathological  anatomy, 

299 
prognosis,  300 
symptoms,  299 
treatment,  300 

acute  pericarditis,  754 

acute  peritonitis,  845 

dermatitis    exfoliativa,    356 

diseases  in  general,  268 

eiysipelas,  491 
.  general  diagnosis,  271 

general  disease,  298 

general  etiology  269 

general  pathological  anatomy,269 

general  prognosis,  271 

general  symptoms,  270 

hemorrhagic  disease,  303 

ichthyosis,  374 

infectious  haemaglobinaemia,  300 

malformations,  268 

maternal  impressions,  271 

of  extremities,  296 

of  head,  272 

of  neck,  281 

of  trunk,  282 

paralysis  of  the,  990 

pemphigus,  355 

syphilis,  513 

syphilis  haemorrhagica,   519 

syphilitic  pseudo-paralysis,  521 

tetanus,  489 

tramnatism,  268 
New  growths,  of  intestines,  795 

of  kidneys,  872 

of  larynx.  659 

of  liver,  840 

of  stomach,  777 
Nipples,  care  of,  111 

Nitrate  of  silver,  in  local  applications,  874 
Nitroglycerine,  doses  of,  464 
Noma   (vide  Stomatitis  gangrsenosa) 

in  measles,  590 
Normal  development,  39 

abdomen,  56 

ascending  colon,  64 

bile,  78 

bladder,  57 

blood-vessels,  55 

bone-marrow,  77 

brain,  46 

csecum,  64 

cord,  39,  77 

cranium,  44 

cricoid  cartilage,  42 

descending  colon,  65 

diameters,  51 

diaphragm,  52 

discharges,  81 

ductus  arteriosus,  54 

ductus  venosus,  54 

dura  mater,  46 

ear,  46 

epiglottis,  42 

Eustachian  tubes,  47 

Eustachian  valves,  54 


Normal  development,  face,  44 

feet,  76 

fontanelles,  44 

foramen  ovale,  54 

functions,  77,  82,  950 

gall-bladder,  56 

hard  palate,  47 

head,  43 

heart.  54 

height,  68,  76 

influence  of  colostnun  period  on 
weight,  70 

intestinal  discharges,  81 

kidneys,  57 

lachrymal  glands,  77 

large  intestines,  64 

larynx,  42 

legs,  105  • 

liver,  56 

lungs,  55 

lymphatic  system,  79 

maxillary  bones,  48 

mental  impressions,  77 

mouth,  48 

naso-pharynx,  46 

neck,  42 

ossification,  51 

pancreas,  56,  78 

petrosquamosal  suture,  46 

pharyngeal  tonsil,  47 

pulmonary  artery,  55 

pulse,  66 

respiration,  52,  67 

salivary  glands,  78 

sigmoid  flexure,  65 

skeleton,  82 

skin,  77 

small  intestines,  63 

spine,  39 

spleen,  56 

sternum,  51 

stomach,  58 

subarachnoid  space,  46 

suprarenal  capsules,  57 

surface  anatomy  of  spine,  41 

sweat-glands,  78 

teeth,  48 

temperature,  65,  66 

thorax,  51 

thymus  gland,  52 

thyroid  gland,  79 

topographical  anatomy,  82 

umbilical  artery,  54 

umbilical  vein,  54 

urine,  79 

vermiform  appendix,  64 

voice,  77 

weight,  55,  68,  76 
Normal  lactation,  evidences  of,  129 
Normoblasts,  903 
Nose,  diseases  of  the,  638 

in  syphilis,  519 
Nursery,  hj-giene  of,  87  to  92 
Nursery-maids,  101 
Nurses  for  premature  infants,  259 
Nursing,  111 

Nutrition,  diseases  of,  313 
Nutritive  period,  first,  109 

second,  232 
third,   235 


1052 


INDEX. 


Nux  vomica,  dose  of,  800 
Nystagmus,  966 

O. 

Oatmeal  jelly,  method  of  making,  184 
Oatmeal  water,  method  of  making,  184 
Oats,  analysis  of  decoctions  of,  168 
Obstetrical  paralysis,  990 
diagnosis,  992 
etiology,  990 

pathological  anatomy,  990 
prognosis,  992 
symptoms,  991 
treatment,  992 
O'Dwyer's  tubes,  469 
(Edema,  acute  circumscribed,  375 
angio-neurotic,  375 
neonatorum,  309 
CEsophagitis,  767 

(Esophagus,  congenital  dilatation  of  the, 
769 
diseases  of  the,  767 
foreign  bodies  in,  767 
Oidium  albicans,  624 
Omodynia,  1026 
Onychia,  late  syphilitic,  531 

sj'philitic,  518 
Ophthalmia  neonatorum,  280 
catarrhal,  280 
purulent,  280 
symptoms,  280 
treatment,  280 
Opium,  doses  of  the  tincture  of,  822 
Orchitis,  816 

Ossification  of  sternum,  30 
Osteo-arthritis,  1028 

Osteo-arthropathy,    hypertrophic    pulmo- 
nary', 1036 
Osteochondritis,  syphilitic,  515,  516 
Osteogenesis  imperfecta,  334 
Osteomalacia,  334 

diagnosis   from  rhachitis,   327 
Osteomyelitis,  acute  infectious,  502 
diagnosis,  503 
from  rhachitis,  326 
etiology,  502 
leucocytosis  in,  504 
pathological  anatomy,  502 
prognosis,  504 
symptoms,  503 
treatment,  504 
Osteoperichondritis,  515 
Osteoperiostitis,  syphilitic,  515 
Otitis    media    (vide   also    Ear)    in    lobar 

pneumonia,  682  i 

Out-of-doors,  when  to  go,  100 
Ovoferrin,  dose  of,  908 
Oxyuris  vermicularis,  831 
Ozsena.  641 


Pachymeningitis,  1005 

Palpation,  in  physical  examination,  238 

Palsies,  birth,  972 

extra-uterine,  972 

infantile  cerebral,  972 
Paludism,  acute,  476 


Pancreas,  at  term,  38 
in  syphilis,  516 

normal  development  of,  56,  78 
tuberculosis  of,  422 
Papers,  in  nursery,  87 
Paralysis,  birth,  297 
bulbar,  1009 
cerebral,  972 
diphtheritic,  459 
Erb's  type,  992 
family  periodic,  1013 
from  caries  of  spine,  989 
hereditary  spastic,  1013 
in  cerebro-spinal  meningitis,  428 
infantile  cerebral,  972 
infantile  spinal,  981 
in  measles,  590 
Landry's,  1010 
obstetrical,  990 
pseudo-bulbar,  1009 
pseudo,  in  syphilis,  521 
Paramyoclonvis  multiplex,  942 
Paramyotonia,  congenital,  942 
Paraplegia,  975 

Parasites,  intestinal  {vide  Worms),  831 
Paregoric,  doses  of,  686 
Parotitis,  611 
Paroxysmal  gasping,  968 
Parrot's  disease,  521 
Pasteurization  of  milk,  175,  217 
Pavor  nocturnus,  962 
central,  962 
peripheral,  963 
Pectus  carinatum,  321 
Pediculosis,  351 
Pediculus  capitis,  351 
Peliosis  rheumatica,  1025 
Pelletierine,  dose  of,  835 
Pelvis,  at  term,  36 
Pemphigus,  infantile,  epidemic,  356 
neonatorum,  35(j 
syphilitic,  518 
Peptonization  of  milk,  in  difTicult  cases,  200 

technique  of,  204 
Percentage  feeding  {vide  Feeding,  indirect 
substitute) 
importance  and   possibilities  of, 
159 
Percentage  modification  of  milk, 
apparatus  for,  184 
calculation  of  combinations, 

187 
caloric  value  of  food  in,  201 
for  premature  infants,  262 
illustrative  cases  of,  221 
materials  for,  183 
mixing  and  administration, 

193 
rules  for  feeding  in,  196 
sources  of  error  in,  201 
theory  of,  180 
use  of  cereals  in,  204 
Percussion,  in  physical  examination,  239 
Perforation  in  typhoid  fever,  440,  448 
Pericardium,  diseases  of  the,  754 
Pericarditis,  acute,  754 

acute  plastic  or  dry,  755 
diagnosis,  759 

differential    diagnosis    from    di- 
lated heart,  761 


INDEX. 


1053 


Pericarditis,  acute,  etiology,  754 
Ewart's  sign  of,  758 
illustrative  cases,  763 
pathological  anatomy,  754 
physical  signs,  755 
point  for  paracentesis,  762 
prognosis,  762 
Rotch's  sign  in,  756,  757 
sicca,  754 
treatment,  762 
with  exudation,  755 
chronic  adhesive,  764 
diagnosis,  766 
symptoms,  765 
treatment,  766 
Perinephritis,  870 
Periosteal  dysplasia,  319 
Peritoneum,  diseases  of  the,  844 
■  non-infectious,  844 
infectious,  844 
tuberculosis  of  the,  396 
Peritonitis,  844 
acute,  844 

.     pneumococcus,  845 
by  extension,  844 
chronic,  847 
congenital,  847 
etiology,  844 
of  the  new-born,  845 
pathological  anatomy,  845 
perforation  in,  844 
prognosis,  846 
symptoms,  845 
traumatic,  845 
treatment,  846 
tubercular,  396 
diagnosis,  398 
etiology,  396 

pathological  anatomy,  396 
prognosis,  399 
symptoms,  397 
treatment,  399 
Peritonsillar  abscess,  653 
Perityphlitis,  828 
Perles  of  Laennec,  672 
Pernicious  angemia,  902 
Peroneal    type    of    progressive    muscular 

atrophy,  1016 
Pertussis,  496 

catarrhal  stage,  496 
complications,  499 
contagium  in,  496 
diagnosis,  499 
etiology,  496 
incubation,  496 
pathological  anatomy,  496 
period  of  infectiousness,  498 
prognosis,  499 
prophylaxis,  500 
spasmodic  stage,  496 
stage  of  decline,  496 
symptoms,  496 
treatment,  500 
Petit  mal,  943 
Petrosquamosal  suture,  46 

at  term,  30 
Petticoat,  infant's,  94 
Pharyngeal  tonsil,  at  term,  28 

normal  development  of,  47 
Pharyngitis,  653 


Pharyngitis,  acute  follicular,  654 
acute  simple,  653 
chronic,  654 
Pharynx,  disease  of  the,  648 
Phimosis,  876 
Phlebitis  umbilicalis,  287 
Phonendoscope,  240 
Phthisis  fibroid,  695 
Picture-mouldings,  in  nursery,  87 
Pigeon-breast,  284,  321 
Pillow,  infant's,  88 
Pin- worms,  831 
Pityriasis,  371 

maculata  et  circinata,  371 
rosea,  371 
rubra,  371 
Plaques  muqueuses,  520 
Plasmodium  of  malaria,  476 

sestivo-autumnal,  476-477 
tertian,  476-477 
quartan,  477 
quotidian,  479 
Pleura,  diseases  of  the,  707 
tuberculosis  of  the,  394 
Pleurisy,  acute,  707 

acute  dry  708 
acute  plastic,  708 
blood,  709 
diagnosis,  711 
encysted,  709 
etiology,  707 
physical  signs,  709 
primary  forms,  707 
prognosis,  711 
.  purulent,  713 
secondary,  707 
symptoms,  709 
treatment,  712 
chronic,  716 
tubercular,  707 
Pleurodynia,  1026 
Pleuro-pneumonia,  708 
Pneumococcus  of  Fraenkel,  674,  675 
Pneumonia,  674 

Pneumonia,  acute  broncho-,  691 
aspiration,  691 
blood  in,  699 
Cheynes-Stokes    respiration 

in,  698  _ 
complications,  699 
cough  in,  698 
cyanosis  in,  698 
deglutition  pneumonia,  691 
diagnosis,  700 
dyspnoea,  698 
emphysema  in,  696 
etiology,  691 
gastro-enteric    synaptoms, 

698 
in  cerebro-spinal  meningitis, 

429 
onset.  697 

pathological  anatomy,  692 
physical  signs,  699 
primary  forms,  691 
prognosis,  700 
pulse,  697 
resolution,  699 
respiration,  697 
secondary   forms,    691 


1054 


INDEX. 


Pneumonia,  acute  broncho-,  suppuration, 
700  i 
symptoms,  696 
temperature,  697 
terminations,  699 
treatment,  701 
tuberculosis  in,  700 
acute  lobular  {vide  Pneumonia,  acute 

broncho-) 
acute  lobar,  due  to  other  organisms, 690 
chronic  broncho-,  695,  704 
hypostatic,  705 
pneumococ(Jfis  lobar,  675 

abortive  form,  680 
apex  variety,  680 
blood-cultures,  678 
central  form,  680,  681 
cerebral  form,  680 
cerebral  symptoms,  677 
complications,  682 
cough,  678 
crisis,  679 

delayed  resolution,  680 
diagnosis,  682 
diagnosis   from   broncho- 
pneumonia, 683 
from  influenza,    684 
from  malaria,   684 
from  meningitis,  684 
from  pleural  exudation, 

682 
.from  tuberculosis  of  the 
lung,  683  _ 
digestive  organs  in,  679 
empyema  in,  682 
etiology,  675 
fulminating  form,  690 
gangrene  in,  682 
illustrative  cases,  687  to  690 
massive  form,  680 
migratory  form,  680 
onset,  676 
otitis  media  in,  682 
pathological  anatomy,  675 
pericarditis  in,  682 
physical  signs,  679 
pleurisy  in,  682 
prognosis,  684 
pulse,  677 
respiration,  677 
rusty  sputum,  678 
skin,  678 

stage  of  congestion,  676 
of  gray  hepatization,  676 
of  red  hepatization,  676 
of  resolution,  676 
symptoms,  676 
temperature,  677 
treatment,  685 
urine,  678 
varieties,  680 
tubercular,  389 
Pneumopericardium,  754 
Pneumothorax,  717 
Podophyllin.  dose  of,  806 
Polio-encephalitis,  1009 
Poliomyelitis,  acute  anterior,  982 
diagnosis,  983 

diagnosis  from  cerebral  paralysis,  984 
from  multiple  neuritis,  984 


Poliomyelitis,  diagnosis   from  progressive 

central  muscular  atrophy,  1014 

from  progressive  neural  muscular 

atrophy,  1016 
from   pseudo-hypertrophic   mus- 
cular dystrophies,  1018 
from    pseudo-paralysis    of    scor- 
butus, 985 
from  rhachitis,  327,  985 
etiology,  981 

illustrative  cases,  986-989 
pathological  anatomy,  981 
prognosis,  985 
symptoms,  982 
temporary  form,  983 
treatment,  985 
Polymorphonuclear  neutrophiles,  884 
Polynuclear  eosinophiles,  884 
Polypus  of  the  nose,  641 

of  the  umbilicus,  288 
Porencephaly,  973 
Posthitis,  876 

Post-natal  changes  in  heart,  54 
Posture,  defects  of,  102 
Potassium  chlorate,  doses  of,  622 
Pott's  disease,  402 

diagnosis  from  rhachitis,  327 
Powder,  prescription  for  bathing,  92 
Pregnancy,  influence  of,  in  lactation,  133 
Premature  infants,  247 

abdomen  in,  249 

air  for,  252 

animal  heat  in,  252 

amylolytic  function  in,  251 

apparatus  for  incubator,  259 

appearance  at  birth,  254 

at  twenty-four  weeks,  248 

at  twenty-eight  weeks,  248 

at-thirty-two  weeks,  249 

at  thirty-six  weeks,  249 

at  thirty-eight  weeks,  249 

Breck's  feeder  for,  260 

brooders,  257 

caloric  needs  of,  261 

circulation  in,  252 

details  of  64  days  in  incubator,  256 

determination  of  age  of,  247 

digestion  of  fats,  sugar,  and  pro- 

teids  in,  251 
feeding  of,  260  to  267 
feet  of,  251 

gastric  capacity  of,  251 
handling  of,  253 
head,  249 
incubators  for,  257 
intestinal  contents  in,  251 
kidneys  of,  252 
length  of,  248,  249 
light  for,  253 

normal  development  of,  249 
nurse  for,  259 
prognosis  of,  264 
pulse  of,  253 
receptacle  for,  256 
respiration  of,  253 
sounds  affecting,  253 
stomachs  in,  250 
sweat-glands  in,  251 
temperature  of,  253 
temperature  of  incubator,  257 


INDEX. 


1055 


Premature  infants,  thorax  of,  249 
treatment  of,  254 
weight  of,  255 
Prescription   writing    {vide    Feeding   and 

Percentage  modification  of  milk) 
Preservatives  in  milk,  167 
Primary  anajmias,  902 
chlorosis,  907 
pernicious,  902 
Proctitis,  826 

Progressive  muscular  dystrophies,  1017 
Prolapse  of  rectum,  795 
Prophylaxis,  value  of,  in  treatment,  246 
Proprietary  foods,  229 
Protargol,  strength  of,  in  injections,  875 
Proteids,    limitations    of,    in    cream-mix- 
tures, 182 
management  of,  in  feeding   {vide  also 
Milk),  198,  220 
Protodaetmi,  293 
Prurigo,  368 
ferox,  368 
mitis  infantilis,  368 
Pseudo-bulbar  paralysis,  1009 
Pseudo-influenza,  469 
Pseudo-membranous  croup,  661 
Psoriasis,  367 
Pulmonary  artery,  at  term,  32 

normal  development  of,  55 
transposition  of  the,  721 
Pulmonary  atresia,  725 
Pulmonary  osteo-arthropathy,     hypertro- 
phic, 1036 
Pulmonary  stenosis.  724 
Pulmonary  tuberculosis,  388 
Pulmonary  valve,  disease  of  the,  745 
insufficiency,  745 
stenosis,  745 
Pulse,  at  term,  36 

variations  according  to  age,  66 
Purpura,  1022 

fulminans,  1024 
haemorrhagica,  1024 
Henoch's,  1023 
i-heumatica,  1023 
simplex,  1022 
Purulent  synovitis,  of  infants,  acute,  502 
Pygemia  of  the  bone,  502 
Pyelitis,  acute,  868 

chronic,  870 
Pyelonephritis,  868 
Pylorus,  stenosis  of  the,  771 
Pyonephrosis,  870 
Pyo-pneumo-thorax,  717 

Q. 

Quartan  type  of  malaria,  477 
Quinine,  doses  of,  482 

R. 

Rachischisis,  287 

Rachitis  {vide  Rhachitis) 

Radiograph  of  chest  and  abdomen,  244 

of  hydropneumothorax',  716,  718 

of  osteomyelitis,  503,  504 

of  rhachitis,  324 

of  syphilis  of  bones,  528 

of  tuberculosis,  504 


Ranula,  279 

Reaction  of  degeneration,  984 
Rectum,  malformations  about,  293 
imperforate  anus,  293 
imperforate  rectum,  293 
prolapse,  795 
protodseum,  293 
»    reflex  symptoms  of,  971 
treatment,  293 
Recurrent  vomiting,  778 
Red  corpuscles,  882,  887 
Reflex  cough,  969 
Reflexes,  dental,  965 

of  ear,  966 

of  heart,  970 

of  larynx,  966 

of  lung,  968 

of  rectum,  971 

of  stomach.  970,  971 

of  vagina,  971 
Rennet-coagulation,    conditions    influenc- 
ing, 171, 172 
Rennin,  171 
Respiration,  52 

at  term,  30,  36 

in  physical  examination,  238 

variation  according  to  age,  67 
Retarded  speech,  953 
Retropharyngeal  abscess,  655 
Rhachitis,  313 

acute,  320 

blood  in,  325 

bone  lesions,  314  to  318 

congenital,  315 

convulsions  in,  320,  324 

craniotabes  in,  320 

diagnosis  of,  326 

etiology,  313 

extremities  in,  323 

foetal,  314,  333 

food,  as  a  cause  of,  315 

funnel-chest  in,  321 

Harrison's  groove,  321 

head  in,  320 

heart  in,  325 

intestines  in,  326 

kyphosis  in,  323 

laryngospasmus  in,  324 

late,  314 

liver  in,  325 

lordosis,  323 

lungs  in,  324 

lymph  nodes  in,  325 

microscopic  lesions  in,  317  ^ 

muscles  in,  324 

nervous  systeni  in,  324 

occurrence,  313 

of  adolescence,  314 

pathological  anatomy,  316 

prognosis  in,  329 

radiograph  of  legs  in,  324 

rosary  in.  322 

scoliosis  in,  323 

spine  in,  323 

spleen  in,  319,  325 

stomach  in,  326 

s>anptoms  of.  319 

thorax  in,  321 

treatment  of.  330 

visceral  lesions  in,  319 


1058 


INDEX. 


Stridor,  congenital,  659 
Strippings,  125 
Strychnine,  doses  of,  464 
Subarachnoid  space,  46 
Substitute  feeding  (vide  Feeding) 

indirect  {ride  Feeding),  158 
Sudauiina,  360 
Sugar-measure,  185 
Sim,  in  nursery,  87 
Sun-stroke,  958 

Suprarenal  capsules,  at  term,  33,  34 
normal  development  of,  57 
Suprarenal  extract,  dose  of,  308 
Sweat-glands,  at  term,  38 

in  premature  infants,  251 
normal  development   of,  78 
Sydenham's  chorea,  932 
Symptoms,  caiises  of,  in  feeding  cases,  200 
Syno^*itis  of  infants,  acute  purulent.  502 
Syphilis,  513 

acquired,  513 
cerebral,  1004 
hereditary,  513 

abortion  in,  514 
bone  changes  in,  515 
Colles's  law,  514 
early  manifestations  of,  517 
alopecia,  518 
anus,  519 
bones,  520 
craniotabes,  521 
dactj'litis,  521 
diagnosis,  522 
digestive  organs,  519 
efHorescence,  517 
eye,  518 

hemorrhages  in,  519 
iodides  of  potassium  in, 

523 
lymph-nodes,  518 
mercurials  in,  524 
mouth,  520 
nails,  518 
nose,  519 
onychia,  518 
pathological  anatomy, 

517 
pemphigus,  518 
plaques  muqueuses,  520 
prognosis,  522 
pseudo- paralysis,  521 
rhagades,  520 
snuffles,  517 
spleen,  523 
s\"mptoms,  517 
teeth,  518 
treatment,  523 
inheritance,  513 
late  manifestations  of,  529 
bones,  529 
ear,  532 
eye,  5.31 

Hutchinson's  teeth,  530 
illustrative    cases,    533, 

535 
infantilism,  530 
interstitial  keratitis,  532 
iodide  of  potassium  in, 

432 
mental  development, 529 


Syphilis,   hereditan,',    late  manifestations 
of,  mercurials  in,  532 
nails,  531 

natiform  skull,  529 
nervous  sj'stem,  532 
onychia,  531 
pathological     anatomy, 

529 
symptoms,  529 
treatment,  532 
liver  in,  516 
miscarriage  in,  514,  526 
pathological  anatomy,    515 
post-conceptional,  514 
retro-infection,  514 
spleen  in,  516 
transmission,  513 
retarded,  513 
Syringomyelia,  1013 
Syringo-myelocele,  284 


Tabes,  juvenile,  1012 
Tache  cerebrale,  404 
Taeniae,  834 
Tape-worms,  834 
Taste,  at  term,  38 
Teeth,  at  term,  29 

in  syphilis,  518 

normal  development  of,  48 
Temperature,  at  term,  36,  65 

for  administration  of  milk,  214 

method  of  taking,  238 

of  incubator  for  premature  infants,257 
Teratoma,  1001 
Testicles,  at  term,  21 

in  syphilis,  516 

tuberculosis  of  the,  423 

tmnors  of  the,  293,  876 

undescended,  292 
Tetanus  neonatorum,  489     ' 
Tetany,  964 

Chvostek's  sjTnptom  in,  965 

diagnosis,  965 

etiology,  964 

pathological  anatomy,  964 

prognosis,  965 

spnptoms,  964 

treatment,  965 

Trousseau's  sjmiptom,  965 
Thomsen's  disease,  941 
Thorax,  at  term,  30 

diameters  of,  51 

frozen  section  of,  53 

in  premature  infants,  249 

in  rhachitis,  321 

normal  development  of,  51 
Throat,  examination  of,  241 

in  scarlet  fever,  540,  564 
Thrombosis  of  the  cerebral  sinuses,  998 
Thrush,  624 
Th^Tnic  asthma,  923 
Thj-mus  gland,  at  term,  32 

diseases  of  the,  923 
relations  of  the,  52 
tuberculosis  of,  422 
Thyroid  gland,  diseases  of  the,  914 
hypersemia  of  the,  915 
in  measles,  589 


INDEX. 


1059 


Thyroid  gland,  size  of,  79 

tuberculosis  of,  421 
tumors  of,  723 
Thyroiditis,  acute,  922 
Tics,  941 

Tinea  circinata,  353 
favosa,  354 
tonsurans,  353 
tricophytina,  353 
versicolor,  354 
Toes,  in  the  new-born,  296 
Tongue,  at  term,  29 
Tongue-depressor,  241 
Tongue-tie,  278 
TonsiUitis,  648 

acute  cryptic,  648 
acute  follicular,  648 
chronic,  651 
Tonsils,  faucial,  at  term,  28 
hypertrophied,  651 
hypertrophy  of  the  pharyngeal,  644 
pharyngeal,  at  term,  28 
Topographical  anatomy,  82  to  86 
Torticollis,  acute,  1026 
Touch,  at  term,  38 
Tourette's  mixture  in  epilepsy,  946 
Toys,  in  nursery,  89 
Trachea,  diseases  of  the,  664 
Tracheotomy,  467 
Transitional  cells,  883 
Traumatism,  in  the  new-born,  268 
Treatment,  general  principles  of,  236,  244 
Tremor,  963 

Tricophyton  tonsurans,  353 
Tricuspid  valve,  disease  of  the,  744 
insufficiency,  726,  744 
stenosis,  726,  745 
Trional,  dose  of,  748 
Trismus,  in  tetanus,  489 
Trousseau's  symptom,  965 
Trunk,  at  term,  22 

diseases  of,  in  the  new-born,  282 
Tub,  for  bathing  infants,  91 
Tubercular    meningitis    (vide    Meningitis, 

tubercular) 
Tuberculin  test,  380 
Tuberculosis,  376 

acute  miliary,  378,  382 

pathological  anatomy,  382 
simulating  infantile  atrophy, 

383 
simulating     typhoid     fever, 
382  _ 
bovine,  in  relation  to  human,  376 
chronic  general,  384 
conglomerate  tubercles,  379,  385 
general,  381 
general  diagnosis,  380 
general  etiology,  376 
general  pathological  anatomy,  378 
general  prognosis,  381 
general  symptomatology,  380 
general  treatment,  381 
localized,  384 
■      of  the  bladder,  422 
of  the  brain,  400 
of  the  bronchial    lymph-nodes, 

387 
of  the  cerebro-spinal  system,  400 
of  the  cervical  lymph-nodes,  385 


Tuberculosis,   localized,    of    the   ileum, 
394 
of  the  joints,  418 
of  the  kidney,  422 
of  the  larynx,  388 
of  the  liver,  422 
of  the  lungs,  388 
lymph-nodes,  384 
.  mesenteric,  387 

pancreas,  422 
peritoneum,  396 
pleura,  394 
skin,  423 
spleen,  422 
testicle,  423 
thymus  gland,  422 
thyroid  gland,  421 
trachea,  388 
miliary  tubercles  in,  379,  385 
mode  of  infection,  377 
predisposition    to,  378 
prophylaxis,  379 
tuberculin  test,  380 
Tuberculosis  of  the  lungs,  388 
|g|  acute  miliary,  388 

chronic  diffuse,  390 
chronic  localized,  390 
tubercular   pneumonia,   388 
Tumor  albus,  421 

Tumors  (vide  also    New-growths),   intra- 
cranial, 1001 
of  testicles,  876 
of  thyroid,  923 
Turpentine  stupe,  448 
Typhoid  fever,  439 

bacilluria  in,  447 
bathing  in,  447 
complications,  443 
diagnosis,  443 

from  acute  ileo-colitis,  444 
from  acute  miliary  tubercu- 
losis, 445 
from  epidemic  cerebro-spinal 

menmgitis,  445 
from  epidemic  influenza,  445 
from  exanthemata,  444 
from   malaria,   445 
from  pneumonia,   444 
from  tubercular  meningitis, 
445 
diazo-reaction  in,  442,  444 
etiologv,  439 
foetal,  439 

hemorrhage  in,  440,  448 
incubation,  441 
in  infancv  and  earlv  childhood, 

439       \ 
leucocytosis  in,  444 
pathological  anatomy,  440 
perforation  in,  440,  448 
prodromal  stage,  441 
prognosis,  446 
rose-spots  in,  440,  442,  444 
sequela?,  443 
sjTnptoms,  441 
technique  of  batli  in,  447 
treatment,  446 

wliitc  blood  count  in,  443,  444 
"Widal  reaction  in,  442,  443 
Typhus  fever,  451 


1060 


INDEX. 


U. 

Ulcer  of  stomach,  777 
peptic,  777 

Umbilical  artery,  20 

post-natal  changes  in,  54 

Umbilical  hemorrhage,  39 

Umbilical  hernia,  288 

treatment,  289 

Umbilical  veins,  20 

post-natal  changes  in,  54 
septic  inflammation  of,  838 

Umbilicus,  fungus  of,  288 
polj'pus  of,  288 

Unclassified  diseases,  1021 

Undescended  testicle,  292 

Ursemia  (vide  Nephritis) 

Uric  acid  infarction,  at  term,  34 

Urine  (vide  the  especial  disease) 
at  term,  39 
incontinence  of,  877 
method  of  collecting,  851 
significance  of,  in  nephritis,  850 
variations  according  to  age,  79 

Urotropin,  dose  of,  873 

Urticaria,  362 
giant,  375 

Uterus,  at  terrn,  36 

Uvula,,  elongation  of  the,  654 


V. 

Vaccination,  599 

Vaccinia,  599 

Vagina,  occlusion  of,  293 

reflex  symptoms  of,  971 
Vaginitis,  874 
Varicella,  603 

complications,  606 

contrasted  with  variola,  606 

diagnosis,  605 

efflorescence,  604 

etiology,  603 

gangrsenosa,  604,  606 

incubation,  604 

pathological  anatomy,  603 

prodromata,  604 

prognosis,  607 

symptoms,  604 

treatment,  607 
Variola,  592 

blood  in,  595 

complications,  596 

con^uent  form,  595 

contagium  in,  592 

desquamation,  595 

diagnosis,  597 

discrete  form,  594 

efl&orescence,  595 

hemorrhagic  form,  596 

incubation,  594 

in  foettis,  592 

modified  form,  596 

pathological  anatomy,  592 

prognosis,  598 

symptoms,  594 

treatment,  598 
Varioloid,  592,  596 
Veins,  at  term,  32 
Ventilation  in  nursery,  89 


Ventricular  septum,  defect  of  the,  724 
Vermiform    appendix,    normal    develop- 
ment of,  64 
Vernix  caseosa,  21 
Verrucas,  371 
Vertigo,  962 
Vitality,  at  term,  37 
Voice,  at  term,  37 

normal  development  of,  77 
Voh-ulus,  792 

Vomiting  (vide  also  Stomach,  functional), 
778 

cj^clic,  778 

periodic,  778 

persistent,  778 

recurrent,  778 
Von  Jaksch's  anasmia,  898 
Vulvo-vaginitis,  874 


W. 

Walls,  in  nursery,  88 

Warts,  371 

Waxy  rigidity,  958 

Weakness,  diagnosis  from  rhachitis,  328 

Weaning,  151 

Weeping  eczema,  363 

Weight,  at  term,  36 

average  daily  gain,  71 
influence  of  colostrum  period  on,  70 
normal  development  of,  68  to  76 
physiological  loss  of,  69 
premature  infants,  255 
Weight-chart,  72 
Weight-index,  73 

chart  illustrating,  74 
Wet-nurses,  154,  156 
diet  of,  157 
selection  of,  156 
Windows,  in  nursery,  87 
Whey,  analysis  of,  168 

method  of  making,  _  184 
Whey-mixtures,  calculation  of,  191 

in  difficult  cases  of  feeding,  199 
in  laboratory  modification,  220 
Whev-proteids,  in  cow's  milk  and  human 

milk,  191 
Whiskey,  as  a  stimulant,  244 
White  blood  count  in  disease  (vide  symp- 
toms or  diagnosis  of  disease  in  question) 
White  corpuscles,  882-887 
Whole  milk,  definition  of,  183  _ 
Whooping-cough  (vide  Pertussis),  496 
Widal  reaction,  442,  443 
Winkel's  disease,  300 
Witches'_milk,_282 
Worms,  intestinal,  831 

ascaris  Imnbricoides,  833 
oxyuris  vermicularis,  831 
tsenise,  834 


X-rays  (vide  Radiograph),  243 


Zahorsky's   rules   for   feeding   premature 
infants,  261 


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